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Full text of "Lectures on the diseases of the nervous system, delivered at La Salpêtrière"

THE NEW SYDENHAM 

SOCIETY. 



INSTITUTED MDCCCLVIII. 



VOLUME LXXII. 



LECTUEES 



THE DISEASES OP 



THE NERVOUS SYSTEM, 



DELIVERED AT LA SALPÊTRIÈRE 



J. M. CHARCOT, \%2Z -{^Sl 

PROFESSOR TO THE FACULTT OV MEDICINE OF PARIS ; PHÏSICIAN TO LA SALPÊtEIÈRE ; MEMBEE 

OF ÏHE ACADKMY OF MEDICINE, AND OF THE CLINICAL SOCIETY OF LONUON- 

PRESIDENT OF THE ANATOMICAI, SOCIETY, AND EX-VICE-PRESIDENT 

OF THE BIOLOGICAL SOCIETY OF PARIS, ETC. 



TRANSLATED BY 

GEORGE SIGERSON, M.D., M.Ch., 

LICENTIATE OF THE KING AND QUEEN's COLLKGE OF PHYSICIANS ; LECTURER ON BIOLOGY AND 

EX-DEAN OF THE FACULTÏ OF SCIENCE, CATHOLIC UNIVERSITY OF IRELAND; PELLOW OF 

THE LINNEAN SOCIETY OF LONUON; MEMBER OF THE SCIENTIFIC SOCIETY OF 

BELGIUM, AND OF THE ROYAL IRISH ACADEMY, ETC. 



LONDON: ^^' ^ '^ '' ^ 

THE NEW SYDENHAM SOCIETY. 

MDCCCLXXVII. 

,8 7-' 






^ «f "^^ 






CONTENTS. 



LECTURE I. 



DISORDERS OF NUTRITION CONSEQUENT ON LESIONS OF 
THE NEUVES. 

PAGE 

SuMMARY. — Prellminary observations. Object of thèse lectures : they 
shall be devoted to those diseases of the nervous system, aud of the 
spinal cord, especially, which are niost usually met with in the Sal> 
pêtrière Hospital. Nutritive disorders conséquent on lésions of the 
eerebro- spinal axis and of the nerves. Thèse morbid altérations 
may aifect the skin, the connective tissue, the muscles, the articu» 
lations, the viscera. Their importance in relation to diagnosis and 
prognosis. Nutritive dérangements conséquent on lésions of the 
peripheral nerves. Slight influence (in the normal state) of the 
nervous System upon nutritive action. Passive lésions of the nerves 
and spinal cord do not directly produce disorders of nutrition in the 
peripheral parts. Démonstrative experiments. Influence of the 
irritation and inflammation of nerves or of nervous centres on the 
production of nutritive disturbances. Nutritive disorders consé- 
quent on traumatic lésions of nerves, considered specially. They arise 
not from complète but from imperfect sections or from contusions, 
&c., of the nerve. Cutaneous éruptions : erythema, zona traumatica, 
pemphigus, " glossy skin." Muscular lésions, atrophy. Articular 
lésions. Lésions of the osseous system : periostitis, necrosis. Dis- 
orders of nutrition conséquent on non-traumatic lésions of the 
nerves; their analogy with those which resuit from traumatic 
lésions. Nutritive disorders affecting the eyes in cases of com» 
pression of the trifacial by tumour. Inflammation of the spinal 
nerves, conséquent on vertébral cancer, on spinal pachymeningitis, 
on asphyxia by charcoal fumes, &c. Cutaneous éruptions (zona, 
pemphigus, &c.), muscular atrophy, and articular affections, which, 
in such cases, are developed in conséquence of the neuritis. Anœs- 
thetic lepra, leprous perineuritis, lepra mutilans . . .3 



VI CONTENTS. 



LECTURE II. 

NUTRITIVE DISORDERS CONSECUTIVE ON NERVE LESIONS 
iContinued). AFFECTIONS OP THE MUSCLES. NUTRITIVE 
DISORDERS CONSECUTIVE ON LESIONS OF THE SPINAL 
COUD. 

PAGB 

SuMMABY.— Anatomical and functional modifications occurring in muscles 
under the influence of lésions of the nerves supplying them. Im- 
portance of electrisation as a means of diagnosis and prognosis. 
Researches of Dr. Duclienne (de Boulogne). Experiments : Long 
persistence of the electrical contractility and of normal nutrition of 
muscles, after the section or excision of motor or mixed nerves in 
the case of animais. Pathoiogical cases : Diminution or speedy 
abolition of the electrical contractility, foUowed by rapid atrophy of 
the muscles in cases of rheumatic paralysis of the facial nerve, and 
of irritative lésions of mixed nerves, whether of traumatic or 
spontaneous origin. Causes of apparent contradiction between the 
results of experiment and the facts of pathology. Application of 
the researches of M. Brown-Séquard : Irritative nerve-lesions alone 
détermine the speedy abolition of electrical contractility, foUowed 
by rapid atrophy of the muscles. Experiments of MM. Erb, 
Ziemssen, O. Weiss. Contusion and ligation of nerves are irrita- 
tive lésions. Différence of the results obtained in the exploration 
of muscles wheu faradisation and galvanisation are employed. The 
results of thèse new researches are comparable with the facts of 
human pathology; they do uot weaken the proposition of M. 
Brown-Séquard. 

Trophic disorders consécutive on lésions of the spinal cord. Con- 
sidered with regard to their influence on the ' nutrition of the 
muscles thèse lésions constitute two well-defined groups. 

First group : lésions of the cord having no direct influence on muscular 
nutrition : a, lésions in circumscribed spots affecting the grey sub- 
stance to but a slight extent vertically, e.g. partial myelitis, tumours, 
Pott's disease ; b, extensive fasciculated lésions of the posterior 
white or the antero-lateral colunms, without the grey matter par- 
ticipating ; e. g. primitive or secondary sclcrosis of the posterior, 
antero-lateral columns, &c. 

Second group : Lésions of the spinal cord which influence, more or 
less rapidly, the nutrition of the muscles : a, fasciculated or cir- 
cumscribed lésions which affect the anterior cornua of the grey 
matter to a certain extent, in heiglit ; central myelitis, ha;raatomyelia, 
&c. ; b, irritative lésions of the large nerve-cells of the anterior 
cornua with or without participation on the |)art of the white fasci- 
culi: infantile spinal paralysis, spinal paralysis of adults, gênerai 
spinal paralyses (Duchenne de Boulogne), progressive muscular 



CONTENTS. 'VU 

PAGE 

atrophy, &c. Prédominant influence of lésions of the grey matter 
in the production of trophical troubles of the muscles. Thèse facts 
can be interpreted by means of Browu-Soquard's proposition , 28 



LECTURE III. 

DISORDERS OF NUTRITION CONSECUTIVE ON LESIONS OF 
THE SPINAL CORD AND BRAIN. 

SuMMABT. — Cutaneous aifections in sclerosis of the posterior columns : 
papular or lichenoid éruptions, urticaria, zona, pustular éruptions ; 
their relations with the fulgurant pains ; the former appear to arise 
from the same organic cause as the latter. 
Eschars of rapid development (acute bed-sores) in diseases of the 
brain and spinal cord. Mode of évolution of this skin-affection : 
erythema, buUae, mortification of the derma, accidents consécutive 
on the formation of eschars : a, putrid infection, purulent infection, 
gangrenons emboli ; h, simple purulent ascending meningitis, icliorous 
ascending meningitis. Acute bed-sore in apoplexy symptomatic of 
circumscribed cérébral lésions. It appears principally in the gluteal 
région of paralysed extremities ; its importance in prognosis. Acute 
bed-sore in diseases of the spinal cord ; it generally occupies the 
sacral région. 
Arthropathies depending on a lésion of the brain or spinal cord. 
A. Acute or subacute forms ; they appear in cases of traumatic 
lésion of the spinal cord ; in myelitis occasioned by compression 
(tumours, Pott's disease), in primary myelitis, in récent hemiplegia, 
connected with cérébral softening. Thèse arthropathies occupy the 
joints of paralysed limbs. B. Chronic forms ; they seem to dépend, 
like amyotrophies of spinal origin, on a lésion of the anterior cornua 
of the grey axis ; observed in posterior sclerosis (locomotor ataxia) 
and in certain cases of progressive muscular atrophy . . • ^3 



LECTURE IV. 

NUTRITIVE DISORDERS CONSECUTIVE ON LESIONS OF THE 
BRAIN AND SPINAL CORD. (CONCLUSION.) AFFECTIONS 
OF THE VISCERA. THEORETICAL OBSERVATIONS. 

SuMMARY. — Viscéral hyperœmia and ecchymoses consécutive on expéri- 
mental lésions of différent portions of the encephalon, and on intra- 
encephalic hsemorrhage. Experiments of Schiff and Brown-Séquard : 
Personal observations. Thèse lésions seem to dépend on vaso-motor 



CONTENTS. 



paralysis : they should form a separate category. Opinion of Scliroe- 
der van der Kolk, relative to the relations alleged to exist between 
certain lésions of the encephalon and différent forms of pneuraonia, 
and pulmonary tuberculisation. HEemorrhage of the supra-renal 
capsules in myelitis. Nephritis and cystitis consécutive on irritative 
spinal affections of sudden invasion, vphether traumatic or spon- 
taneous. Rapid altération of the urine under thèse circumstances; 
often remarked contemporaneously vi^ith the development of eschars 
in the sacral région; its connection vrith lésions of the uriuary 
passages which are due to direct influence of the nervons system. 
Theory of the production of nutritive disorders consécutive on lésions 
of the nervous system. InsufSciency of our présent kuowledge, 
■with respect to this question. Paralysis of the vaso-motor nerves ; 
consécutive hyperaemia ; trophic disorders not produced. Excep- 
tions to the rule. Irritation of the vaso-motor nerves : the consé- 
quent ischsemia seems to hâve no marked influence on local nutri- 
tion. Dilator and secretor nerves : researches of Ludvpig and 
Claude Bernard; analogies between thèse two orders of nerves. 
Theoretical application of trophic nerves. Samuel's hypothesis. 
Exposition. Criticisms. Conclusion . , . -103 



LECTURE V. 

ON PARALYSIS AGITANS. 

SuMMAKY. — Of tremor in gênerai. Its varieties. Intermittent tremor. 
Continuons tremor. Influence of sleep, rest, and voluntary motion. 
Distinction established by Van Svirieten. Opinion of M. Gubler. 
Tremor, according to Galen. Paralysis agitans, and disseminated 
sclerosis, — independent diseases. Parkinson's researches. French 
Works : MM. Sée, Trousseau, Charcot, and Vulpian. Paralysis 
agitans admitted to the right of domicile in classic treatises. 

Pundamental characters of paralysis agitans. A disease of adult life. 
Its symptoms. Modifications observed in the gait. Tendency to 
propulsion and retropulsion. Invasion ; its modes, slow or abrupt. 
Period of stationary intensity. Ilead and neck not afi'ected by 
tremor. Altérations of speech. Rigidity of the muscles. Attitude 
of the body and limbs. Déformation of the hands and feet. Delay 
in the exécution of movements. Perversions of eensibility. Cramps ; 
gênerai sensation of tension and fatigue : need of fréquent change 
of position. Habituai feeling of excessive beat. Température in 
paralysis agitans. Influence of the kind of convulsions — static or 
dynamic. 

Terminal period. Confinement to bed. Disorders of nutrition. En- 



CONTENTS. IX 



feeblement of tlie intellect. Sacral eschars. Terminal complaints : 
they difFer from those of disseminated sclerosis. Duration of para- 
lysis agitans. 

Necroscopical results. Inconstant lésions in paralysis agitans ; fixed 
lésions in disseminated sclerosis. Lésions of tlie pons Varolii and 
of the meduUa oblongata (Parkinson, Oppolzer). Pathological 
physiology. 

Etiology. External causes ; violent moral émotions ; influence of 
damp cold, wlien much prolonged ; irritation of certain peripheral 
nerves. Predisposing causes. Influence of âge. Paralysis agitans 
appears at a more advanced period of life than disseminated sclerosis. 
Sex. Hereditary prédisposition. Influence of race . .129 



LECTURE VI. 

DISSEMINATED SCLEROSIS. PATHOLOGICAL J^NATOMY. 

SoMMAKY. — History of disseminated sclerosis ; French period ; German 
period ; New French investigations ; Macroscopic morbid anatoniy ; 
external aspect of the patches of sclerosis ; their distribution iu 
brain, cerebellum, protuberantia, bulbus rachidicus, and spinal cord. 
Patches of sclerosis on the nerves. Spinal, cephalic or buibar, and 
cerebro-spinal forms. Characters of the sclerosed patches ; their 
colour, consistence, &c. 
Microscopic anatomy ; sketch of the normal histology of the spinal 
cord ; Nerve-tubes ; Neuroglia, its distribution ; Cortical layer of 
the recticulum. Characters of the neuroglia, influence of chromic 
acid. Arterial capillaries. Histological characters of the sclerosed 
patches ; transverse sections ; peripheral zone ; transition zone ; 
central région. Longitudinal sections. Altérations of the blood- 
vessels. Examiuation of the sclerosed patches in the fresh state. 
Histological lésions consécutive on section of the nerves. Fatty 
granulations in sections of the sclerosed patches observed in the 
fresh state. Modifications of the nerve-cells. Mode of succession 
of the lésions . . . . . . -157 



LECTURE VII. 

DISSEMINATED SCLEROSIS: ITS SYMPTOMATOLOGY. 

SuMMARY. — Difi'erent aspects of disseminated sclerosis, considered frora 
a clinical point of view. Causes of error in diagnosis. 
Clinical examinatiou of a case of disseminated sclerosis. Tremor: 



CONTENTS. 



PAGE 



modifications caused thereby, in the handwriting ; characters whioh 
distinguish it from the tremor of paralysis agitans, chorea, gênerai 
paralysis, and the motor incoordination of ataxia. 

Cephalic symptoms. Disorders of vision : diplopia, amblyopia, nystag. 
mus. Impeded utterance. Vertigo. 

State of the inferior extremities. Paresis. Remissions. Absence of 
disorders of sensibility. Commixture of rare symptoms; tabetio 
phenomena ; muscular atrophy. Permanent contracture. Spinal 
epilepsy ........ 182 



LECTURE VIII. 

APOPLECTIFORM SEIZURES IN DISSEMINATED SCLEROSIS. 
PERIODS AND EORMS. PATHOLOGICAL PHYSIOLOGY. 
ETIOLOGY. TREATMENT. 

SuMMARY. — Apoplectiform seizures. Their frequency in disseminated 
sclerosis. General considérations ou apoplectiform attacks in gênerai 
paralysis, and in cases of circumscribed cérébral lésions of old stand- 
ing (hsemorrhage and ramollissement). Pathogeny of apoplectiform 
seizures ; insufficiency of the congestion theory. Symptoms : state 
of the puise ; élévation of the central température. Apoplectiform 
seizures in old cases of hemiplegia. Importance of température in 
diagnosis. 

Periods in disseminated sclerosis. First, second, and third periods. 
Symptoms of bulbar paralysis. Eorms and duration of disseminated 
sclerosis. 

Pathological physiology : relation betvfeen symptoms and lésions. 

Etiology. Influence of sex and âge. Hereditary prédisposition. 
Previous nervous affections. Occasional causes : prolongea action 
of moist cold ; traumatism ; moral causes. 

Proguosis. Treatment . . . . . . 203 



LECTURE IX. 

HYSTERICAL ISCHURIA. 

SuMMAKY. — Introduction. Hysterical ischuria. Différences which divide 
it from oliguria. General considérations. Supplementary vomitiug. 
Historical sketch. Causes which hâve thrown doubt on the exist- 
ence of hysterical ischuria. Distinction between calculons ischuria 
and hysterical ischuria. 
Case. Hysterical paralysis and contracture. Complète hemianaesthesia. 



CONTENTS. XI 



Hemiopia and achromatopsia. Ovarian hypersBsthesia. Rétention 
of urine. Tympanitis. Convulsive seizures ; trismus. Manifesta- 
tion of hysterical iscliuria. Précautions taken to guard against 
errer. Complète auuria. Uraernic vomiting. Relation of the 
quantity of urine excreted to the vomited matter. Chemical analysis 
of vomited matter, urine, and blood. Suspension of phenomena. 

Reappearance of hysterical ischuria. New results of chemical 
analyses. 

Serions nature of common anuria and of expérimental anuria. 
Limit of the duration of accidents compatible with life. Influence 
of the évacuation of even a minute quantity of urine. Rapid ap- 
pearance of symptoms in calculous ischuria; their tardiness in 
hysterical ischuria. Innocuousness of symptoms in direct ratio 
with the quantity of urine secreted. Résistance to inanition in 
hysteria, 

Mechanism of hysterical ischuria. Iraperfect supply of information 
in relation to this subject . . . . . .225 



LECTURE X. 

HYSTERICAL HEMTAN^STHESIA. 

SuMMARY. — Hemianaesthesia and ovarian hypersesthesia in hysteria. Ere- 
quent association of thèse two symptoms. Erequency of hemianaes- 
thesia in hysterical patients ; its varieties, complète or incomplète. 
Characters of hysterical hemianaesthesia, ischsemia and the " Con- 
vulsionnaires." Lésions of spécial sensés. Achromatopsia. Relations 
between hemiansesthesia, ovarian hypersesthesia, paresis, and con- 
tracture. Variation of symptoms in hysteria. Diagnostic value 
of hysterical hemianaesthesia; necessary restrictions. 
Hemianaesthesia depending on certain encephalic lésions. Its analogies 
with hysterical hemianaesthesia. Cases in which encephalic hemian- 
aesthesia resembles hysterical hemianaesthesia. Seat of the encephalic 
lésions capable of producing hemianaesthesia. Eunctions of the 
optic thalamus ; British theory ; French theory. Criticism. Ger- 
man nomenclature of différent parts of the encephalon. Its ad- 
vantages as regards the circumscription of lésions. Case of hemian- 
aesthesia recorded by Tiirck ; spécial seat of the encephalic lésions 
in thèse cases. Observation of M. Magnan. Altération of spécial 
sensés ........ 246 



XU CONTENTS. 

LECTURE XI. 
OVARIAN HYPERJISTHESIA. 



PAGE 



SuMMAKY. — Local hysteria of British authors, Ovarian pain ; its fre- 
quency. Historical remarks. Opinion of M. Briquet. 

Cbaracters of ovarian liyperœstbesia. Its exact position. Aura hys- 
terica : first node ; globus hystericus, or second node ; cephalie 
phenomena or tlurd node. The starting-point of the first node in 
the ovary. Lésions of the ovary. Desiderata. 

Relations between ovarian bypersesthesia and the other accidents of 
local hysteria. 

Ovarian compression. Its influence on the attacks. Modus operandi. 
Ovarian compression as a means of arrestingor preventinghysterical 
convulsions known in former times. Its application in bysterical 
épidémies. Epidémie of St. Médard — the remedy termed " secours," 
Analogies which exist between the arrest of bysterical convulsions 
by compression of the ovary, and the arrest of the aura epileptica 
by ligature of a limb. 

Conclusion from a therapeutical point of view. Clinical observations . 262 



LECTUEE XII. 

HYSTEEICAL CONTHACTURE. 

SuMMAKY.— Forms of bysterical contracture. Description of the hémi- 
plégie form ; analogies and différences between bysterical contracture 
and that resulting from a circumscribed lésion of the brain. Ex- 
ample of the paraplégie form of bysterical contracture. 
Prognosis.— Sudden recovery in some cases. Scientific explanation of 
certain reputedly miraculous events. Incurability of contracture 
in a certain number of bysterical patients. Examples. Anatomical 
lésions. Sclerosis of the latéral columns. Varieties of contracture. 
Hysterical club-foot ...••• 283 



CONTENTS. XlU 

LECTURE XIIL 
HYSTERO-EPILEPSY. 

PAGE 

StJMMARY. — Hystero-epilepsy. Meaning of this term. Opinions of 
autliors. Epileptiform hysteria ; bysteria with mixed crises. 
Varieties of hystero-epilepsy ; hystero-epilepsy with distinct crises ; 
hystero-epilepsy with corabined crises, or attaques-accès (seizure 
fits). Différences and analogies between epilepsy and hystero- 
epilepsy. Diagnostic signs supplied by esamination of central 
température in hystero-epileptic acme, and in epileptic acme. Epi- 
leptic acme ; its phases. Clinical characters of hysteria, epileptic 
acme. Gravity of certain exceptional cases of hystero-epilepsy. 
Case recorded by Wunderlich . . . . , 300 

APPENDIX. 

Case of Paralysis Agitans . . . . . 'Si? 



TEANSLATOH'S PREFACE. 



Although but recently published in Paris, the Lectures of Pro- 
fesser Charcot on Diseases of the Nervous System hâve already taken 
a place amongst the classic works of médical literature, and been 
translated into several Continental languages. When preparing for 
thefollowing version, it was judged best to await the appearance of 
the second French édition ; thus the reader, in exchange for 
some delay, has been enabled to obtain the work in its most correct 
form, enlarged by about one sixth. It was found inconvénient to 
reproduce the ten plates appended to the French volume ; neverthe- 
less, the références made to them, in the text, hâve been preserved, 
with a view to facilitate the researches of those who may désire to 
consult the original designs. 

It is proper to mention that thèse lectures were reported and 
edited in French by Dr. Bourneville, editor of ' Le Progrès Médical/ 
whose name or initial will be found attached to several notes. 

G. S. 

Dublin. 



PART FIRST. 



DISORDERS OF NUTRITION CONSEQUENT 

ON LESIONS OF THE BRAIN AND 

SPINAL CORD. 



LECTURE I. 

DISOflDERS OF NUTRITION CONSEQUENT ON LESIONS 
OF THE NERVES. 

SuMMARY. — Frelimînary observations. Ohject of thèse lectures: 
they sTiall he devoted to those diseuses of the nervous System, and 
of the sonnai cord, especially, which are most usually met zoith 
in the Salpétrïère Hospital. Nutritive disorders conseqiient on 
lésions of the cerehro-sphial axis and of the nerves. Thèse 
morhid altérations may affect the shin, the connective tissue, the 
muscles, the articulations, the viscera. Their importance iti 
relation to diagnosis and prognosis. Nutritive dérangements 
conséquent on lésions of the perlpheral nerves. Slight influence 
[in the normal staté) of the nervous System upon oiutritive action. 
Passive lésions of the nerves and spinal cord do not directly 
produce disorders of nutrition in the peripher al parts. Démon- 
strative experiments. Influence of the irritation and inflam- 
mation of nerves or of nervous centres on the production of 
nutritive disturbances. Nutritive disorders conséquent on 
traumatic lésions of nerves, considered specially. They arise 
notfrom complète but from imperfect sections orfrom contusions, 
8fc., of the nerve. Cutaneous éruptions : erythema, zona 
traumatica, pemphigus, '^ glossy skin." Muscular lésions, 
atrophy. Articular lésions. Lésions of the osseous System : 
periostitis, necrosis. Disorders of nutrition conséquent on non- 
traumatic lésions of the nerves ; their analogy with those tohich 
resuit from traumatic lésions. Nutritive disorders affecting 
the eyes in cases of compression of the trifacial by tumour. 
Inflammation of the spinal nerves, conséquent on vertébral cancer, 
on spinal pachymeningitis, on asphyxia by charcoal fumes, 8fc. 
Cutaneous éruptions [zona, pemphigus, ^c), muscular atrophy^ 
and articular affections, lohich, in such ca^es, are developed in 



4 PRELTMINAEY OESEEVATIONS. 

conséquence of the neuritis. Ânœsthetic lepra, lepwns jî?er^- 
nenritis, lepra mutUans. 

Gentlemen, — Never without émotion, yet iiever witliowt great 
gratification^, do I inaugurale, each session, tlie séries of lectures, 
whicli you hâve assembled to hear. On sucli occasions, indeed, I 
never fail to discover the friendly faces of former students, some of 
whom hâve attained professorial rank, and some of whom hâve 
already signalized their career by brilliant researches. Their pré- 
sence affords me a great satisfaction, and I ghidly seize the occasion 
to testify my gratitude. 

It seems to me that the unusual number of those who hâve assem- 
bled hcre to-day is a convincing proof of the correctness of my 
belief vvhen, five years ago, I ventured to maintain that this vast 
emporium of human suffering might one day become a seat of 
theoretical and clinical instruction, of uncontested utihty.^ 

It is true, gentlemen, that the field of observation before us does 
not embrace the entire of pathology. But, taken for what it is, 
who shall complain of its extent, or say that it is not vast ? On 
the one hand, it offers for our study the ailments of the aged, which 
call for a share of our attention. On the other hand, amongst 
chronic diseases, it exhibits, under conditions peculiarly favourable 
to research, and gathered together in numerous array, those diseases 
of the nervous and of the locomotor Systems which are so common, 
and consequently so interesting to the physician — diseases the 
pathology of which has begun, within the last twenty years, to- 
émerge from the deep darkness which had previously covered it. 

As for myself, gentlemen, I hâve never doubted that the Hospital 
of La Salpêtrière was destined to become, both for the diseases of 
old âge and for many chronic disorders, an incomparable centre of 
instruction. Ail that was required to realize this idea was that 
certain modifications should be made in the internai arrangement of 
this institution, and I amhappy to inform you that circumstances, 
at présent, seem wholly favourable to our views. 

The authorities hâve already, without any solicitation, placed 
under our care wards containing nearly one hundred and fifty beds, 
where we may study ail the forms of epilepsy and of the graver 
hysterical affections. The Director of the Assistance Publique has 
also formed the project of opening in this hospital a dispensary 
> This lecture was delivered in May, 1870. 



FRELIMINARY OBSERVATIONS. 5 

--speeiaîly destmed for patients suffering from clirouic aliments, and 
■a ward to wliich a certain number of them should be admitted, tem- 

porarily, to undergo treatment. 

When ail thèse éléments of study sliall liave been classed and 

organized with a view to scientific investigation and clinical 
■ instruction, I bave no hésitation in saying that we shall possess 

at Paris an institution which, of its kind, can scarcely hâve a rival.^ 

I hope to bave soon the happiness of seeiug- this plan realized in ail 
vits détails. But if unforeseen cirçumstances should call me else- 

where, it would still yield me a deep gratification to see my 
-successors crovvning the édifice whose first foundations only I had 

been allowed to build. 

Gentlemen, your time is valuable, and I do uot désire that this 

preamble should extend too far. It is time to corne to the spécial 

subject of thèse lectures. I purpose then to dévote this session to 
4he study of those diseases of the nervous system, and especially of 

the spinal cord, which are most usually met with in this hospital. 

As I feel it would be objectionable to plunge at once into technical 

détails, it seemsto me suitable to invite your attention to a question 

of gênerai interest, and one which we shall encounter at every step in 

the course of our studies. 

I. 

Lésions of the cerebro-spinal axis frequently react upon différent 
, portions of the body and produce there, by means of the 
iierves, various disorders of nutrition. Thèse secondary affections 
constitute one of the most interesting pathological groups, and I 
«hall therefore dévote several sittings to trace out foryou the prin- 
cipal featuresof their history. 

The consécutive lésions in question may affect most of the tissues, 
• and may occupy the most diverse régions of the body; thus, we may 
iind them in the skin, the connective tissue, the articulations, the 
bones, and even the viscera. They generally présent, at least at 
the beginning, the characteristics of inflammatory action. Fre- 
,quently they play in the drama of disease but an accessory part, 
-being simply added on to the usual symptoms, hyperœsthesia, 
-ansesthesia, hyperkinesis, akinesis, motor incoordination, &c. But 
-were it only for the interest they hâve, when considered from the 

1 This project lias, unfortunatelj, not yet beeu made a reality (September, 



6 DISOEDEES OP NUTEITION. 

staud-point of pathological physiology, tliey should not be 
neglected. 

Occasionallj, however, tliese lésions assume an uumistakable im- 
portance in the eyes of the clinical observer, either because of tlie 
serions ailments which they cause, or because of their value as re- 
gards diagnosis or prognosis. Allow me to offer some examples in 
support of tins assertion. 

Last year I pointed ont to you, and I shall return to this 
symptom again, that the sacral escbar wliich is developed in tbe 
course ofapoplexyfrom cérébral htemorrhage or from softening of the 
brain allows us to lay down a prognosis of almost absolute certainty. 
The sacral eschars, the affections of the kidneys and of the bladder, 
which are produced with such rapidity in certain acute diseases 
and in the exacerbations of some chronic diseases of the spinal cord, 
are often the immédiate cause of death. 

An arthropathy, arising in the course of locomotor ataxia, may 
deprive the patient of ail future use of a limb which might other- 
wise bave served him long. 

rinally, thèse consécutive lésions of nutrition sometimes deceive 
the physician, who may mistake them for the disease itself. Such, 
for instance, are certain forms of progressive muscular atrophy 
which were formerly regarded as primary affections of the muscles 
themselves, and whose origin really lies in certain inorbid altérations 
which hâve taken place in the grey matter of the spinal cord. 

It would, I believe, be superfluous to multiply exaraples, for 
thèse observations should now suffice to indicate the interest Avliich 
belongs to the study of such lésions of nutrition. 

The power of producing, under certain morbid conditions, lésions 
of nutrition, in the peripheral parts of the body or in the viscera, is 
not an attribute of the brain and spinal cord alone. Thèse centres 
share the privilège with the nerves which radiate from them. And 
it is to be observed that the consécutive affections produced by pro- 
topathic lésions developed in the most widely différent régions of the 
nervous system présent most remarkable analogies, in spite of some 
spécifie différences. lience when the physician's attention has been 
called to such affections it is often a question of extrême difïiculty 
to détermine what portion of the nervous system was originally 
affected, and what is the true cause of the trophical lésion. 

This considération has induced me not to limit our study to tlie 
lésions which are assignable to cérébral or spinal causes alone. 



DISOEDERS OF NUTRITION. 7 

Thèse sball be^ if you will^ our objective point ; but it seems useful to 
draw out_, in parallel lines, tlie history of those trophical troubles 
which appear in conséquence of lésions of the peripheral nerves. 
Is it not, indeed, one of the greatcst advantages of the comparative 
method that it créâtes light by contrasts ? In order to bound our 
field of study, we shall, however, only take into considération those 
nutritive disorders which appear in the peripheral domain of the 
siiffering nerve, The trophical changes which take place in consé- 
quence of reflex action, in a région more or less remote, and within 
the domain of nerves which hâve uudergone no primitive lésions, 
constitute undoubtedly an interesting subject_, but one which deserves 
to be treated specially. 

II. 

In hearing me speak, gentlemen, of the nutritive disorders which 
arise under the influence of lésions of the nervous centres or of the 
nerves, most of you, I am sure, hâve been immediately reminded of 
the corresponding problem which is debated in normal physiology. 

There is nothing hetter estahlished in jmthologi/ (as I hope to 
demonstrate) than the existence qf trophical troubles consecpient on 
lésions of the nervous centres or qf the nerves. Nevertheless, you 
are aware that the most advanced physiology teaches that, in the 
normal state, the nutrition of différent parts of the body does not 
essentially dépend upon the influence of the nervous System. 

Thèse statements appear contradictory, but the opposition is 
only in appear ance and not in reality. This I shall endeavour to 
prove, and with that object I hâve to ask your permission to make 
a short incursion into the domain of expérimental physiology. 

You are aware that in order to show that the chemical acts of 
molecular rénovation, which constitute nutrition, are not im- 
mediately dépendent on the action of the nervous System,' many 
kinds of arguments are adduced : 

1°. The most complex acts of nutritive life take place in certain 
organisms without the intervention of a nervous System. Plants, 
for instance, and some of the lowest animais, such as certain 
protozoa, though unprovided with nervous Systems, manifest great 
vital activity. Does not the embryo, it is also asked, perform ail 
the acts of organic life, at a period when it as yet possesses no 
nervous élément whatever ? 

2°. They base another argument on the fact that certain 



■8 INFLUENCE OF NEKVE-SECTION. 

tissues, even iu the superior animais, are totally devoid of nerves 
and vessels. As instances, they refer to the epithelial layer and to 
cartilage, which if placed under patliological conditions will become 
seats of cell- prolifération — a plain proof tliat nutrition can take 
place tliere in a very energetic manner.^ 

3°. Finally, arguments bearing more directly on the subject 
are drawn from the arsenal of expérimental physiology. You 
know that, after section of the nerves supplying them^ and even 
■when the spinal cord has been destroyed, the peripheral parts of 

*..."The whole organic life of animais, e. e. everything which goes on in 
them without the interveutiou of any sensation, or other mental act, may go 
on without tlie intervention of the nervous System and stands in no relation of 
dependence to any cliange in nervous matter ; just as the corresponding functions 
of circulation, nutrition, sécrétion, absorption, go on in equal perfection in the 
lowest class of animais where no nerves are detected and iu the whole veget- 
able kingdom, where there is no plausible reason for supposing that nerves 
exist ; . . . the nervous System lives and grows within an animal as a parasitic 
plant does in a vegetable." — ' British and Foreign Med.-Chir. Review,' vol. iii, 
1837, pp. 9, 10 ; and Carpenter, ' Principles of Human Physiology,' Phila- 
delphia, 1855, p. 59. 

The foUowing is a succinct analysis of an essay, in which M. Charles Robin 
lias quite recently expounded the prévalent ideas of the présent day in référ- 
ence to the far from promineut rôle which the nervous system plays in the work 
of nutrition : — " Those chemical acts which, in a living organism, constitute 
molecular rénovation, otherwise called nutrition, are not under the direct 
influence of the nerves. There can be no question hère of an influence of 
■nerves over tissues, comparable to that of electricity upon chemical action. 
There exist no nerves which extend over the extra-vascular anatomical éléments, 
such as the epithelium, like those nerve-tubes which proceed and are applied 
to Ihe muscular fibrils. The cause of the movement of nutrition lies in the 
anatomical cléments themselves. In plants, where no nervous system is found, 
we see the tissues suddenly swell, the cells increase and multiply. lu the em- 
bryo, cells are formed, and increase and multiply, before tlie appcarance of 
any peripheral nerve-element. Nutrition is, therefore, a gênerai property of 
anatomical éléments, be they animal or vegetable. Sécrétion itself is a property 
inhérent in anatomical éléments, as De Elainville and A. Comte hâve observed. 
In the lower animais, and in the case of animal grafts, it is évident that the 
nutrition of tissues is iudependent of the nervous system." "Disordcrs of sécré- 
tion and of absorption, indurations, softenings, hypertrophies, and other 
altérations consécutive ou nerve-Iesions, are a conséquence of perturbations of 
the circulation through the médium of the preceding (vaso-niotor) nerves, 
directly affcctcd by rcflcx action, and are not a conséquence of the action of 
nerves which sliould, like electricity, hâve an influence over the molecular or 
chemical acts of assimilation and dis-assimilation in a zone of a certain extent 
bcyond their surface." — ' Journal de l'Anatomie,' &c., 1867, pp. 276 — 300. 



INFLUENCE OF NERVE- SECTION. 9 

the body, such as the muscles or the bones of a limb, will continue 
to live and be nourislied for a considérable time, almost as efficiently 
as tbough they were under normal conditions. In such cases, 
lésions of nutrition do not make tlieir appearance until a com- 
paratively long period bas elapsed. Even then they are almost always 
ipurely passive, and seem, in reality, due to the state of inaction to 
which the parts are condemned in conséquence of the suppression 
of nervous influence. This belief is supported by the fact tliat 
lésions, displaying similar characteristics, présent themselves when 
limbs are kept in a state of immobility, though the nervous System 
be not directly implicated. Such passive lésions, which we sliall 
meet with in différent paralytic affections, hâve nothing in common 
with the spécial trophical lésions which engage our attention. 
Generally they can be distinguished from them, objectively, by 
certain particular signs. 

The spécial lésions are almost always characterized, at some 
period of their évolution, at least, by évidence of phlegmasic irri- 
tation. From the commencement they usually take on the appear- 
ance of inflammation ; and they may, as we shall see, issue in ulcé- 
ration, gangrené, and uecrosis. There is, besides, one characteristic 
common to most of them, and that is the great rapidity of their 
development, after the lésion of nerves or nervous centres which 
provokes their manifestation. Sometimes they make their appear- 
ance with incredible quickness. Thus we frequently see eschars 
visible on the sacrum, the second or third day after the accident, 
in certain cases of fracture of the backbone, with compression and 
irritation of the spinal cord. 

It may therefore be laid down as a gênerai rule that there is a 
striking distinction betweeu jjassive lésions, resulting from func- 
tioual inaction alone, and trojpJiic disorders which folio w on certain 
lésions of the nervous centres. The former are slow of production 
and usuallv manifest no symptom of inflammation ; the latter often 
suddenly break out and generally présent, at least at the commence- 
ment, more or less notable signs of phlegmasic irritation. 

AUow me, gentlemen, to remind you, briefly, of some of the experi- 
ments to which I hâve just alluded, and which tend to demon- 
strate that the nerves and spinal cord hâve no direct immédiate 
influence upon the nutrition of peripheral parts. 

1°. One of the first of thèse relates to the section of the ischiatic 
nerve in mammalia. Schroeder van der Kolk, who was one of the 



10 INFLUENCE OF NERVE-SECTION. 

earliest to make the expérimenta attributed the disorders of nutri- 
tion wliich foUowed, with some rapidity in sucli cases, in the cor- 
responding member, to the abolition of the action of the nervous 
System in conséquence of the section. M. Brown-Séquard repeated 
the expérimenta in 1849^ on guinea-pigs and rabbits, and succeeded 
in sho\^"ing that the trophical troubles whiqh follow in the course of 
a few days, and which consist of tuméfaction of the extremity of the 
member, ulcération of the toes, loss of the nails, only make their 
appearance because the animal is no longer able to préserve the 
limb, now devoid of movement and sensation in conséquence of the 
section of the ischiatic, from the action of external influences, such 
as contact with the hard rough ground over which it is dragged. 
Wben the animal experimeuted on was placed under proper condi- 
tions, confined in a box, for instance, the bottom of which was 
covered with a thick Tayer of bran, there was no modification of 
nutrition to be remarked in the paralysed member, except a more or 
less perceptible atrophy which, however, only made its appearance 
slowly in the course of time.^ 

ïhis atrophy which follows the section of the ischiatic nerve, evi- 
dently results from the functional inaction to which the paralyzed 
limb is condemned. It affects not only the muscles, but also the 
bones and the skin, as J. Eeid bas already remarked. It will not be 
produced, even when the section bas been complète, if, following the 
example of the physiologist quoted, you take care to pass a gal- 
vanic current daily through the muscles of the paralysed member. 

2°. The complète section of the trifacial nerve, made within the 
cranium, présents results perfectly in keeping with those produced 
by section of the ischiatic. You are aware that the lésions of the 
eye which are found in animais subjected to this opération, and 
which were formerly considered by some physiologists as the consé- 
quence of the abolition of the nutritive influence of the trifacial, 
hâve, since the experiments of Snellen in 1857 and those of Biittner 

^ Brown-Séquard, " Sur les altérations pathologiques qui suivent la section 
du nerf sciatique," ' Comtes-rendus des Séances de la Société de Biologie,' t. i, 
1849; and 'Expérimental Ilesearclies applicd to Pliysiology and l'athology,' 
New York, 1863, p. 6. 

After tlic section of a mixed ncrvc the atrophy of tiie muscles does not 
generally begin to show itself, in man and mammalia, by a slight emaciation, 
iinlil the end of about a month. At the close of the second month it is more 
marked ; it is very évident at the end of threc months. — Magnin, Thèse de 
l'aris, 1866, p. 19. 



SECTION OF SPINAL COBD. 11 

in 1862, been recognized as resultingfrom tlie consécutive anjiesthesia 
wliicli exposes tlie parts, deprived of sensation, to ail kinds of 
traumatic causes. If tlie eye be protected after the section of the 
nervc, cither by Snellen''s method of tying the still sensitive ear of 
the same side in front of it, or by Biittner's plan of covering it 
with a pièce of thick leather, the trophical troubles will not make 
their appearance in the cornea. A certain amount of neuro-para- 
lytic hypercemia in the iris and conjunctiva is, in short, the only 
phenomenon observable, after section of the trifacial, when the eye 
has been properly protected.^ 

3°. With respect to the spinal cord it seems demonstrated that 
a complète transverse section, or even its destruction for a certain 
length, when resultiug in no considérable inflammation of the organ,. 
is not immediately followed by troubles of nutrition in the para- 
Ijsed members. M. Brown-Séquard has shown that the ulcérations 
whicli appear, rather quickly, in the vicinity of the génital organs 
of mammalia and birds, after complète transverse section of Hie cord, 
are not direct conséquences of the absence of nervous influx. They 
are produced by the prolonged pressure, and the contact of fœcal 
matters and decomposed urine, to which thèse parts are exposed. 

The hinder limbs of a young cat, which survived for nearly three 
months the complète destruction of the lumbar région of the spinal 
cord, were seen to develop in a normal manner. The functions of 
organic life seemed to proceed there in due accordance with physiologi- 
cal order ; the sécrétion of claws and hair went on as in a healthy and 
uninjured animal." 

According to Valentin, when the posterior portion of the spinal 
cord has been destroyed, in mammalia and frogs, you will find the 
electrical contractility of the muscles of the hind members persist 
until death supervene, that is to say, for several weeks or even 
several months after the opération.^ 

Tosumup: in those animais whose spinal cords hâve been com- 
pletely divided transversely, or extirpated in part, ulcérations and even 
eschars may form, principally in those régions subject to pressure; 

^ See the experiments of M. Schiff relating to tliis subject in tlie thesis of 
M. Hauser, entitled ' Nouvelles recherches relatives à l'iiiflueuce du système 
nerveux sur la nutrition,' Paris, 1858. 

" Browu-Séquard, /oc. cil., pp. 14, 15, 16. 

^ Valentin, 'Versuch eiuer Physiologischen Pathologie der Nerven,' 2 Abth.> 
p. 43, Leipzig, 1864. 



13 INFLUENCE OP VASO-MOTORS. 

but it is always possible to attribute thèse lésions to the ansesthesia 
-and paralysis, in conséquence of whicli the animal lies constantly in 
contact with its excréments or uuwittingly wounds itself, when 
dragging about its paralysed members. As to the atrophy which 
supervenes, in the long run, in the paralysed limbs after this opéra- 
tion, it arises solely, as in the case of the section of the ischiatic 
nervc; from the functional inertia to which they are condemned. 

It follows from ail thèse facts, which expérimental physiology 
offers, that the abolition of the action of the nervous System, whether 
determined by complète section of the peripheral nerves or by de- 
struction of a portion of the spinal cord, produces no other nutri- 
tive disturbance in the anatomical éléments of the paralyzed members 
than what would be caused in the same éléments by the influence 
-of functional inertia, or prolonged inaction alone. 

The discovery of the vaso-motor nerves and of the effects which 
follow the paralysis of thèse nerves was not destined to modify this 
formula» in any essential manner. It is in fact demoustrated at 
présent, that neuro-paralytic hypersemia, however far it may go, is 
iiever of itself alone sufïicient to cause an altération in the nutrition 
of tissues. Undoubtedly, this hypersemia, as M. Schiff has pointed 
eut, créâtes a certain prédisposition to inflammatory action, which 
may supervene either spontaneously (to ail appearance, at least) 
in the diseased animal or in conséquence of irritative causes which 
would be comparatively trifling in a healthy organism. But lésions 
of nutrition of neuro-paralytic origin are nowise comparable to the 
trophical troubles which forra the spécial object of our study, — they 
■constitute a class apart. The latter, as we shall frequently hâve 
occasion to observe, may develop and accomplish their évolution 
without being preceded or accompanied by any of the phenomena 
which betray the paralytic state, or the contrary condition, of the 
vaso-motor nerves. At présent we shall dwell no longer upou this 
subject, which we shall hâve an opportunity of referring to here- 
after. 

III. 

If lésions, whose conséquence is the abolition or suspension of 
the action of the nervous system, are impotent to produce in 
distant parts other nutritive disturbances than those attributable to 
prolonged inaction, U is not ilins as regards lésions loliich détermine 
either in the nerves or nervous centres an exaltation of their 
jpro]pertics, an irritation , or an inflammation. 



INFLUENCE OF NEEVE-IRRITATION. 15 

Tliatj gentlemen, is a proposition of capital importance : it 
control?^ in fact, tlie question which engages our attention. Althougli 
long since discovered by M. Brown-Séquard the principle upon 
which it reposes is stillj if I do not mistake, too frequently ovcr- 
looked botli by physiologists and by pathologists.^ We shall find in 
due time and place, that human patliology présents many facts and 
décisive arguments in support of this proposition. On the other 
liand, we shall hâve less frequently to quote the results of experi- 
raents on animais. The especial reason of this paucity lies, 
undoubtedly, in the fact that the uervous tissue of animais seems 
inuch better able than that of man to resist the influence of the 
diverse causes of irritation and inflammation. AU experimenters 
are aware that even the most serious traumatic lésions of the spinal 
cord or of the peripheral nerves do not readily produce, in the case 
of most animais, a myelitis or a neuritis, having some duration, which 
could be considered comparable with those developed so quickly in 
man, after the very slightest lésions. 

The experiments which go to show that irritative lésions of the 
nerve-tissues are capable of determining varions trophical troubles 
in the parts they supply, are, as we hâve said, few in number. 
They relate almost exclusively to the fifth pair. 

The following is an abridged account of an experimeut of 
Samuel : 

In the case of a rabbit, two needles are applied to the 
Casserian ganglion and an inductive current produced : imme- 
diately ensue a more or less marked contraction of the pupil, 
and at the same time a slight injection of the vessels of the con- 
junctiva. The lachrymal sécrétion is greatly increased. The 
sensibility of the eyelids, conjunctiva, and cornea is augmented. 
After the opération, the contraction of the pupil persists, though not 
to the same extent, and the hypersesthesia is still further increased. 
Inflammatory action generally sets in at the end of twenty-four 
hours ; it iucreases in intensity during the second and third days 
and then gradually diminishes. Ail the stages of ophthalmia may 
be observed, from the slightest conjunctivitis to the most intense 
blenuorrhœa. The exaltation of the sensibility still proceeds, and 

^ ' Note sur quelques cas d'affectiou de la peau, dépendent d'une influence du 
système nerveux,' par J. M. Charcot, suivies de " Remarques sur la mode d'in- 
fluence du système nerveux sur la nutrition," par le docteur Brown-Séquard, 
' Journal de Physiologie,' t. ii. No. 5, p. 108, 1859. 



14 INFLUENCE OF NERVE-IKRITATION. 

tlie hypersesthesia may rise to such a degree that, at the sliglitest 
touch of the eye, the animal is seized with gênerai convulsions. On 
the cornea a gênerai opacity develops, and we find, besides, some- 
times little exulcerations, sometimes a solitary oval-shaped ulcer 
occupying the middle portion of tins membrane. In one case a 
small purulent collection formed in the anterior chamber. Hypersemia 
excepted, no pathological altérations of the iris, neither adhérions nor 
changes of colour, are ever observed. 

In every instance, hypersesthesia of the ophthalmic branches of 
the fifth pair is specifically remarked. Hence it is plain that we 
cannot hère, as in the experiments of Snellen and Biittner, invoke 
the aid of ansesthesia in order to explaiu the trophical troubles 
supervening in an imperfectly protected eye.^ 

After an unsuccessful attempt to divide the trifacial in a rabbit, 
Meissner observed certain remark able lésions of nutrition to ensue 
in the eye, which liad preserved its sensibility. The author care- 
fuUy points out that thèse lésions loere producecl witliout Iiavhig heen 
preceded hy cmy sign of neuro-paralytic liyperœmia. A post-mortem 
examination revealed that the (internai) médian part of the trifacial 
alone had been woiinded by the instrument (a neurotome).- Schiff 
also cites four cases, in support of Meissner's observation, of partial 
lésions of the trifacial in the cranium, which were followed by 
inflammation of the eye, although its sensibility persisted.^ 

In Samuel's experiment trophical troubles arose in the eye, in 
conséquence of faradaic irritation of the fifth pair. May we not 
infer that, in the experiments of Meissner and Schiff, the lésions of 
the eye were caused by phlegmasic irritation developed in the nerve 
in conséquence of the imperfect section ? In support of this opinion, 
I would remind you that incomplète sections, in man, are much 
raore likely than complète sections to give rise to irritative action. 
This fact has long been familiar to surgeons. We may suppose 
that it holds good, at least to some extent, in the case of animais 
as well as of man.* 

' Samuel, 'Die Tropliischen Nerven,' Leipzig, 1860, p. 61. 

2 G. Meissner, " Ueber die nacli der Durciisclineidung der Trigeminus am 
Auge der Kauinchens Eintretcnde Ernaliruugstarung," ' Ilenle und Pfeufer's 
Ztsch.' (3), xxix, 96-104. ' Ceiitralblatt,' 1867, p. 265. ' Gazette Hebdomadale,' 
1866, p. 634. 

•■' Schiff, ' Henle's Zeitsch.' (3), xxix, 217-229. ' Centralblatt,' 1867, p. 655. 
' Gazette Ilebdom.,' 1867, p. 634. 

^ Tiiis is not the interprétation which Meissner proposed for bis experiment. 



INFLUENCE OP NERVE-IERITATION. 15 

Let me place, side by side, with thèse facts several observations 
recorded in référence to the human organism, to which I shall after- 
wards recur, They relate also to the trifacial nerve. Like the 
preceding experiments, they show that irritative lésions of this nerve, 
spontaneously developed, may also, without being followed by 
ansesthesia, give rise to very striking nutritive disorders in the eye. 

A woman, aged 57, whose case has been noted by Bock,i ex- 
perienced, for about a year, violent pains in the right side of the 
face. Thougli intermittent at first, they became afterwards almost 
continuons. The sensibility of the face never completely disap- 
peared; sHght pressure was, indeed, scarcely felt, but if the pressure 
was increased, it brought on acute pains. The conjunctiva of the 
right eye was injected. The cornea, slightly opaque ail over, pre- 
sented a hypertrophie ulcération in its lower part, of about two lines 
in length. Afterwards, the ulcération increased in depth, and the 
opacity of the cornea was augmented. Perforation at last ensued, 
and, under the influence of pressure, issue was given to a puriform 
liquid. Death took place unexpectedly. On a post-morteni exami- 
nation the Casserian ganglion of the right side was found to be of 
considérable volume and very hard. The three branches of the 
right trifacial were likewise found much thickened up to the point 
of their émergence from the bone. 

The following case is taken from a memoir by rriedreich.- 

A man, aged 6^, was suddenly smitteu by hemiplegia on the right 
side, with loss of sensibility on the same side. Some weeks before 

He supposes that the iunermosfc flbrils of the trifacial, which had alone been 
eut, in the case quoted, hâve a spécial action on the nutrition of the eye. He 
bases his opinion on this that, in three other cases where the trifacial had 
undergoae incomplète section, but where the innermost nerve-fibrils had been 
respected, no trophical troubles in the eye ensued, although this organ which 
had lost its sensibility was not protected from external agencies. We think 
that incomplète sections need to be repeated a considérable number of times 
before it is possible to pronounce a deflnite judgment on the interprétation 
propoSed by Meissner. 

1 Bock, 'Ugeskrift for Laeger,' 1842, vii, p. 431. Extract in ' Hannover's 
Jahresbericht,' ' MuUer's Archiv,' 1844, p. 47, and Schiff's ' Untersuchungen 
zur Physiologie des Nervenssystems mit Berûcksichtigung der Pathologie,' 
Frankfurt am Main, 1855, pp. 61,, 64. 

" Friedreich, 'BeitrJige zur Lehre von den Geschwiilsten, innerhalb der 
Schaedelhohle,' Wurzburg, 1843, p. 15, and Schiff's ' Untersuchungen,' &c., 
p. 100. 



16 INFLUENCE OP NEEVE-IRRITATION. 

this attack he had felt slight laucinating pains in tlie left side of 
the face and in the globe of tlie left eye. Thèse pains increased 
rapidly and to a high degree after the apoplectic attack. At the 
same time the conjunctiva of the left eye became injected, and there 
was an increase of the lachrymal sécrétion : later on, the conjunc- 
tiva was coated by a pseudo-raembranous puriform exudation. The 
left pupil, though very much contracted^ was still sensitive to the 
action of light. Sensibility remained normal over the whole of the 
left side of the face. 

At the autopsy there was found at the surface of the middle 
peduncle of the cerebellum a collection of little sarcomatous 
tumours, which, taken altogether, were about the size of a filbert. The 
adjacent brain-substance, especially next the cerebellum, was softened 
and very much injected. The left trifacial nerve, at its émergence 
from the base of the encephalon, was red, slightly softened, and 
flattened by the tumour. 

It would be easy to quote a considérable number of cases analo- 
gous to those \ve hâve cited, but thèse will suffice for the object we 
hâve now in view.i 

^ Facts relating to nutritive disorders of tlie eye, consécutive on spontaneous 
lésions of j,he fifth pair in mau, are numerous enougb, but we liave only wished 
to mention those in which it was well establisbed that the facial sensibility had 
net been touched. The two following cases, however, are also deserving of 
notice although they are not so explicit, in this respect, as those of Bock and 
Freidreich. 

A vigorous individual, after a blow received upon the head, became subject 
to violent fîxed pains, on the right side of the head, and suffered occasioually 
from epileptic fits. Afterwards, the pains became localizcd in the right eye and 
car. The eye was red, tumefied, and projecting, but still covered by the 
paralysed upper eyelid. Turbid cornea ; iris, contracted and motionless ; 
brown-coloured at first, then greenish. The cornea became, at length» 
opaque. 

Post-mortem. — The lower surface of the anterior and middle lobes présent, 
on the right side, several steatomata of the size of a beau, or almond. The 
Casserian ganglion and the three branches of the trifacial are covered over by a 
stiff cartilaginous mass. The motor oculi is compressed, and its colour altered. 
The statc of the sensibility of the skiu of the face is unl'ortunatcly not given 
in this case. F. A. Landmann, ' Commentatio pathologico-atomica exhibons 
morbum cerebri oculique singularem; ' in-4°, Leipzig, 1820, and ScliilT's 
'Untersuch.,' p. 51. 

In the well-known case recorded by Serres, 'Journal de Physiologie,' v, 
182,5, pp. 223, and ' Anatomie comparée du Cerveau,' in spite of the profound 
altération of the Casserian ganglion and of the roots of the larger fasciculus of 



CONTRADICTOEY EXPERIMENTS. 17 

Apart from the fifth pair, expérimental lésions of other nerves are 
still more rarely found to détermine the appearance of trophical 
troubles in the periplieral parts. We should quote, however^ as 
-cxamples of tliis species, the remarkable effects produced upon the 
nutrition of the kidneys by lésions of the nerves supplying them. 
Amongst the experimenters some, like Krimer, Brachet, Muller and 
Peipers, A. Moreau, and Wittich, assert that they can, almost with 
certainty, produce,, by means of thèse lésions, more or less deep- 
seated altérations in the kidneys. Others, however, such as Paul 
Bert and Hermann, on repeating the same experiments uuder appa- 
rently identical conditions, déclare that they obtaiued nothing but 
négative results. 

May we not, at least partially, account for this singular contradic- 
tion, in the following manner : no rénal lésion was manifested when 
nerve-sections had been complète and thorough ; on the contrary, 
such lésion appeared, or, perhaps I should say, may hâve appeared 
when the section was imperfect, or when the scalpel was replaced by 
caustics, by ammonia for instance (Corrente, Scliiff), thèse being cir- 
cnmstances eminently proper to détermine in the injured nerves a 
more or less active irritation or even to set up manifest intlammatory 
action.^ Prom this point of view the question would probably 
deserve to be revised with the help of uew researches. 

We mentioned, a little time ago, the effects of transverse sections 
and partial destruction of the spinal cord in so far as regards the 
nutrition of parts deprived of feeling and motion in conséquence of 
such opérations. We said that, when the opérations did not give 
rise to intlammatory action in the injured cord, (and this takes place 
in the great majority of cases), there are found in the paralysed 
members simply a degeneration with atrophy of the muscles, very 
slowly supervening, ulcérations of the derm, and perhaps eschars 

the trifacia!, there was not complète paralysis of the seusitive portion of the 
nerve, for the whole surface of the face had preserved the sensé of feeliug. 
There had been acute inflammation of the right eye, with œdema of the lids, 
obnubilation and subsequently complète opacitj of the cornea. The right 
•Casserian ganglion was of a greyish yellow, tumefied, and moist with a serons 
exudation. That portion of the ganglion where the ophthahnic nerve arises 
was red and injected. The roots of the larger fasciculus presented a dirty 
bue, contrastiug with tlie colour of the lesser branch, wliicli had remained 
bealthy. The three nerves, on issuing from the ganglion, were of a yellow 
colour, whlch disappeared at their exit from the cranium. 

^ See ' Zeitschrift fiir ration, Med.,' 35 Bd., p. 343. 

2 



18 IRRITATION OF SPINAL CORD. 

caused by dragging over a rough surface, or by continuous contact 
with decomposed urine, and want of cleanliness. In one word, ail 
the effects, to wliich functional inertia of the liinder member of ani- 
mais give lise, are présent, and thèse only. But the scène changes 
completely if, in conséquence of circumstances that cannot be fore- 
seen, nor as yet produced at will, inflammation is set up in the 
vicinity of the spinal lésion. Then, indeed, as M. Brown-Séquard 
has shown, and as I hâve had many opportunities of observing, 
muscular change takes place with great rapidity ; in but a few days 
after the opération, the altération is very manifest. The emaciation 
of the muscular masses soon becomes appréciable, and makes very 
quick progress. Eruptions appear on the skin which promptly issue 
in the formation of ulcérations and of eschars, though the most 
minute care be taken to préserve cleanliness. They develop espe- 
ciaUy in those régions which are subject to pressure, to friction, to 
prolonged contact with the urine ; but they may also make their 
appearance apart from thèse conditions, although the cases are 
rare,^ 

I might dwell, at length, on thèse trophic troubles connected 
with traumatic inflammation of the spinal cord in animais, but it 
will be more appropriate to recur to the matter when studying the 
features of myelitis, spontaneously developed in man. Besides, I 
hâve no désire to prolong overmuch this incursion into the field of 
expérimental physiology. We hâve already obtaiued one resuit, if 
I mistake not ; the facts quoted suffice, it seems to me, to establish 
that the abolition oftJie action of ilie nervoiis System has no direct 
immédiate influence on the peripheral parts — on the other hand, 
they make it appear at least extremely probable that morhid 
excitation or irritation of the nerves or nerve-centres are of a 

^ It is doubtless in the same manner, that is, by invokinf:^ the existence of 
inflammation about the injured point, that we should explain the disorders that 
sometimes occur in the nutrition of the eye, in many animais,' after section of 
a latéral half of the spinal cord, in the back. Tlie affections of the eye 
(ulcérations, melting away of the cornea, purulent conjunctivitis), observed by 
M. Brown-Séquard in the guinea-pig (' Comptes-Ecndus de la Société de 
Biologie,' t. ii, 1850, p. 134) hâve been met with by M. Vulpiaii, in the frog, 
after the section of the correspondiiig half of the cord, near the medulla 
oblongata (this fact was orally communicated). Such affections do not super- 
vcne in ail animais which hâve been thus opcrated on, and it is at least highly 
probable that they arise only in cases where, conséquent on the section, au 
iûflammatory action was set up in the superior segment of the spinal cord. 



TEAUMATIC NEEVE-LESIONS. 19 

nature to give rise to the most various nutritive dérangements in 
distant parts. 

By what means or mechanism does this irritation of the nervous 
System react upon the peripheral parts, and détermine there lésions 
of nutrition such as those we hâve mentioned? Are thèse due 
to an irritation of the vaso-motor nerves or to their paralysis? 
Or do they dépend on an irritation of those hypothetical nerves, 
which anatomy as yet knows not, and which are sometimes called 
lâ'ophic nerves? Thèse are questions which we shall hâve to 
discuss hereafter ; at présent we must return to the domain of 
human pathology, and I hope to make you acknowledge that the 
principle already set out by expérimental physiology has its applica- 
tion hère in a still more manifest manner. This principle shall be 
our due, and it will lead us, I hope, to comprehend why lésions, 
which appear at first sight similar and which are referrible to the 
same points of the nervous or peripheral Systems, should produce, 
in pathological cases, results so opposite and even so contradictory 
in appearance. 

The trophic troubles which we purpose to pass in review are 
produced : 

1°. By lésions of the peripheral nerves, which lésions may be 
either due to traumatic causes or spontaneously developed. 

2°. By lésions of the spinal cord and of the meduUa oblongata. 

3°. By lésions of certain portions of the encephalon. 

Trophic Disorders conséquent on Lésions of the Nerves. 

Let us commence by considering lésions of the nerves. They 
présent the simplest conditions of study. Surgery, in this respect, 
supplies us with records of great value ; for traumatic lésions of 
the nerves are occasionally to be observed in the human organism, 
under conditions of simplicity comparable with those accompanying 
the expérimental lésions inflicted on animais. 

A. At the outset, I shall establish what I consider to be a 
fundamental distinction between thèse traumatic lésions of nerves, 
the importance of which you will soon perceive. i°. The lésion 
sometimes consists of a clean and complète section, in which case 
the effects are merely, speaking generally, those resulting from the 
absence of nerve-action ; 2°, sometimes, owing to contused or 
lacerated wounds, the lésion is of such a nature as to set up 



20 AFFECTIONS OF THE SKIN. 

irritation iu the nerve, in wliich case, and then only, we see arise 
those tropliical troubles to which I invite your attention. Let 
us fîrst consider the cases belonging to the second group. 

The traumatic nerve-lesions iti question may give rise to morbid 
phenomena affecting the skin, the subcutaneous cellular tissue, 
the muscles, the joints, and the bones. You are aware that the 
last American war has furnished occasion for some very important 
studies on this subject; they hâve been given to the public by 
Dr s. Weir Mitchel, Morehouse, and Keen in an interesting work 
of which we shall often avail ourselves.^ To one of my former 
students, the late lamented Mougeot, we also owe a very remark- 
able treatise on cutaneous affections developed under the influence 
of lésions of the peripheral nerves. It is not to be expected 
that I can enter into détails, and consequently I must refer any of 
you who désire to investigate this question fuUy, to the thesis of 
Mougeot, in which ail records relative to the subject hâve been 
most carefully brought together." 

a. Sk'm affections. — The accidents which traumatic nerve-lesions 
may occasion in the integuments are of several kinds : 

1°. The first includes éruptions, of varions forms, but chiefiy 
those characterised by vesicles and bulla3. We shall cite, in the 
first place, the zona [herpès zoster), which is frequently observed in 
such cases, and which on that account might be designated zona 
traumaiica. I described, at the time, a very fine spécimen of this 
kind, observed at the hospital of La Charité, under the treatment of 
my master, Eayer.-^ The American surgeons, already mentioned, 

^ S. Weir Mitchel, G. E.. Morehouse, and W. Keen, ' Guushot Wounds 
and other injuries of Nerves.' Philadclphia, 1864. Extract in 'Archives 
Générales de Médecine/ 1865, t. i. Tiiis work lias been translated into Freuch 
.by Dr. Dastre (1874). 

2 J» B. A. Mougeot, ' Recherches sur quelques troubles de nutrition cou- 
eecutives aux affections des nerfs,' Paris, 1867. 

' "A patient, admitted into Dr. Raycr's wards in 1851, Lad duriug the 
troubles of June, 1848, received a bullet iu the outer inferior part of the tiiigh. 
Some timeafter the wound had healed, acute pains in the leg supervened, which 
were almost continuous, but with occasional cxaccrbations. Thèse pains, which 
seemcd to start from the cicatrix, extended io the dorsum of the foot, and fol- 
lowed evidently the course of the nerves. This neuralgia, which resisted ail incans 
of cure cmploycd, was several times, during the patient's sojourn at La Charité, 
acconipanicd by an éruption of herpctic vesicles, arraugcd in grou;)s closcly 
resembling those of herpès zoster and occupying the skin of the painl'ul parts.' 



AFFECTIONS OF THE MUSCLES. 2V 

have describedj under the name of eczematous éruptions, an affection 
of the skin whicli may be placed witli this form. 

2°. The second kind includes pemphigoid éruptions, of which 
I have also described a well-marked spécimen. Hère we see the 
pemphigus buUse developing with great rapidity, and reappearing 
from time to time on différent parts of the tegumentary System sup- 
pKed by the wounded nerve. They leave after them well-nigh 
indelible scars. This kind of éruption is sometimes seen on vicious 
cicatrices, and is then most probably due to irritation set up in some 
nerve-filament which bas been either strained or compressed in the 
cicatricial tissue. 

3°. In the third place we may note a cutaneous redness, whicÈ' 
resembles erytliema pernio ; ^ and a certain tuméfaction of the skin 
and subcutaneous cellular tissue, as remarked by Hamilton, which 
simulate phlegmon (pseudo-phlegmon).^ 

4°. rinally, we have that cutaneous affection which bas been 
described by the American surgeons under the name of " Glossy 
Skin.^^ The skin becomes smooth, pale, and bloodless; the 
sudoriparous glands are atrophied, and their sécrétion is diminished; 
the epidermis is cracked, and the nails likewise are cracked and 
curved in a very remarkable manner. Hère, in fact, we have to 
deal with a peculiar inflammation of the skin, which recalls some of 
the features of the disease known as scleroderma. 

è. Affections qf the Muscles. — The muscles waste away often in a 
very rapid manner, and lose sometimes partially, sometimes com- 

Charcot, " Sur quelques cas d'affection de la peau, dépendant d'une influence 
du système nerveux," 'Journal de Physiologie,' t. ii, No. 5, Janvier, 1859. 

In the sanie Journal, an analogous case was recorded by M. Rouget. " A 
husbandman, whilst lea])ing a trench, received a charge of rabbit-shot from bis 
gun, in the middle région and on the iuner side of the left arm. In the bottoov 
of the wound, which was over three inches wide, one saw the brachial artery^ 
the torn basilic vein and several contused nerves, especially the internai brachial 
cutaneous. The wound healed quickly enough, but in about from two and a 
half to three nionths, there supervened a herpes-like éruption on the posterior- 
internal part of the forearm, occupying an area of some two inches in diameter, 
in a portion of the forearm deprived of feeling. Examples of herpès following 
on a contusion over the course of a nerve (Oppolzer), or resulting from a straia 
or an effort (Thomas), are far from rare." {Vide Mougeot, loc. cit., p. 38.) 

' Charcot, loc. cit., ' Eruption particulière siégeant sur la face dorsale d'une 
main et des doigts, et probablement consécutive à la lésion des filets nerveux 
qui se distribuent a ces parties.' 

- Mougeot, loc. cit., p. 30. 



22 AFFECTIONS OF THE JOINTS AND BONES. 

pletely, tlieir electrical contractility. But this muscular atropliy will 
form the subject of a spécial study. 

c. Affections of the Joints. — Traumatic nerve-lesions produce, in 
relation to the joints^ symptoms wliich recall in a marked mauner 
the features of subacute, articular rheumatism. Thèse arthropathies 
usually terminate in anchylosis. 

d. Affections of the Bones. — Under similar circumstances we 
occasionally find periostitis produced, often followed by necrosis. 

But I shall not proceed further with this brief enumeration, as 
what we hâve seen will suffice for our purpose. It is important, 
especially at présent, to endeavour to specify, as exactly as possible, 
the particular conditions under the influence of which thèse trophical, 
troubles are developed, after traumatic lésions of the nerves. 

Paget, who was one of the first to call attention to thèse acci- 
dents, does not hesitate to confess his ignorance in relation to them.^ 
The American surgeons, on the other hand, whom we hâve already 
quoted, hâve succeeded in determining the conditions in question, 
and tlieir testimony is the more valuable to us hère, because it is 
based upon observation alone, wholly empirical, and free from any 
preconceived idea. After having remarked, as indeed Paget had 
done before them, that thèse consécutive affections are almost always 
preceded or accompanied by burning pains (evidently correlated to 
an irritative condition of the injured nerve), whilst anœsthesia is 
almost altogether absent, they explicitly point ont that thèse dis- 
orders usually take place after contusions, punctiires, incom/plete 
sections of the nerves, — that is to say, after traumatic causes which 
are most compétent to produce neuritis, or at least the neuralgic 
condition. On the other hand, and upon this our authors insist, 
thèse dérangements are not observed to follow complète sections of the 
nerves the common conséquences of the abolition of nervous action 
being the only phenomena perceptible in such cases. 

It should be added, in conclusion, that the peripheral affections 
which are attributable to nervous irritation, occur spontaneously in 
tlie mojority of cases, witliout the intervention of pressure, or of any 
external cause whatever.^ 

But thèse can only be looked upon as very gênerai conditions : 
we should be able to penetrate more deeply and seek whether there 

• Paget, ' Médical Times and Gazette,' Loudon, March 26, 1864. 
- 'Gunsbot Wound?,' etc., loc.cit., pp. 71-77, aud 'Archives Générales de 
Médecine,' t. i, 1865, pp. 188, 191, 194. 



INFLUENCE OF NERVE-IREITATION. 23 

does not exist in tlie affecied iierves a constant anatomical lésion 
that can be correlated with the manifestation of the peripheral 
lésions. Unfortunately^ we must confine ourselves liere to pointing 
out a lacuna which future research will not, undoubtedlj, fail soon 
to fill. However, the symptoms, taken as a whole, plead already 
in favour of the existence of a neuritis. In addition, we may appeal 
to the necroscopical results which hâve been obtained, in certain cases 
of organic nerve-lesions, in which thewhole séries of peripheral affec- 
tions that we hâve learned to recognise as a conséquence of traumatic 
lésions may be observed, Infûct, in thèse cases, (which will shortly 
engage our attention), the afFected nerves hâve been sometimes found 
tumefied, infiltrated with exuded matter, and greatly congested. Ex- 
amined under the microscope, we discern a more or less well- 
marked multiplication of the nuclei of the tube-sheaths (sheaths of 
Schwann) or of those of the neurilemma and sometimes, moreover, 
ail the signs of grauular degeneration of the medullary cylinders. 
Nothing as yet, however, proves that an irritation capable of deter- 
mining the production of remote trophic troubles may not exist 
in the nerve without beiug betrayed by such comparatively coarse 
lésions. It is opportune hère to point out that every neuritis does 
not necessarily entail the manifestation of trophic troubles. The 
case is quite otherwise. In order that thèse should follow, the 
intervention of certain circumstances is required, which analysis has 
not as yet enabled us to describe. The fact mentioned stands out 
in contrast with what we know of those lésions which supervene, 
in distant parts, after complète nerve-sections, for the latter may be 
looked upon as obligatory and inévitable conséquences of every 
nerve lésion which absolutely deprives the parts in question of the 
influence of the nervous system. 

However this be considered, the influence of the irritation of a 
nerve upon the development of the nutritive dérangement with 
which we are concerned, is set under a strong light and rendered 
manifest, as it were, by the observation of cases in which thèse acci- 
dents, after a teraporary disapjîearance, are seen to be reproduced on 
every reappearance of the irritative cause. As an example, I will 
mention a well-known and often quoted case, which Paget relates 
on the authority of Dr. Hilton : 

A patient, under treatment in Guy's Hospital, for fracture of the 
inferior extremity of the radius was found to hâve acquired a volumi- 
nous callus which compressed the médian nerve. Ulcers that proved 



24 SrONTANEOUS NERVE-LESIO^'S. 

rebellious to ail curative efforts had formed, in conséquence,, on thc 
skin of the thunnb and of the first hvo Angers of the hand. By 
flexing the wrist so as to relax the soft parts of the palmar sur- 
face and tlms to relieve the nerve from compression, it was alwajs 
found possible to bring about the cure of the ulcers in a fevv 
days. But as soon as the patient tried to make use of his haiid 
the nerve was again subjected to compression and the ulcers were 
were observed to reappear with but little delay.^ 

B. It now remains for us to consider those trophic disorders 
which arise in conséquence of spontaneously developed, non-trau- 
matic, nerve-lesions. As I hâve given you to understand, \ve shall 
hère encounter the whole séries of affections whicli we hâve just re- 
viewed. This circumstance will perniit me to deal briefly with the 
matter; it is enough to quote some typical examples, the majority of 
which I borrow from the rich treasury of facts accumulated in M. 
Mougeot^s work." 

To demonstrate the existence of a transition I\vill mention, in the 
iirst place, certain cases in which an influence, not properly traumatic 
but yet belonging to the mechanical order, bas determined an affec- 
tion of the nerve. It is manifestly in this manner that trophic 
disorders of the eye, conséquent on lésions of the trifacial, are pro- 
duced, as in such cases the cause is usually found to be this, 
namely, that intracranial tumours, developed in the vicinity of the 
nerve, détermine in it by compression a more or less active irrita- 
tion Avithout effecting any solution of continuity m the nerve- 
tubes. Cancer of the vertébral column may, as you are aware, bring 
on softening of tlie vertebrœ to such an extent that the laminœ give- 
way and the intervertébral notches are narrowed. The nerves in 
their transit through thèse foramina are consequently compressed), 
irritated, and sometimes becomeinflamed. Under such circumstances 
I hâve seen an herpetic éruption occupy, on the right side, ail the 
cutaneous régions supplied by branches of the cervical plexus, in 
conséquence of the compression to which the nerves that go to form 
it were subjected, in their exit through the spinal foramina. The 
cervical portion of the cord itself and the roots of the cervical 
nerves were healthy, as the post-mortem examination showed, but on 
opening the right foramina the spinal ganglia and the nerve trunks 

• J. Paget, 'Lectures on Surgical Patlioloc'y,' v. i, p. 43. 
- Motifijeot, loc. cil., cliaj). ii, "Des lésions organiques des nerfs et {Ie3~ 
troubles de nutrition consécutifs." 



IISU^LAMMATION OF THE SPINAL KEEVES. 25> 

were found tumefied and of a vivid red colour. Moreover^ in tlie 
gaiiglia as in the iierves we saw, ou a microscopical examination,. 
tliat tbere had been a vast multiplication of nuclei. On the con- 
trary, the gauglia and uerves of tlie left side presented uo trace of 
altération. 1 

It is highly remaïkable to find tbat an inflammation, strictiy 
limited to the spinal gauglia and nerves, may be devcloped 
spontaneously and without the intervention of any raechanical cause, 
giving lise nevertlieless, as Von Biirensprung bas sbown^ to an 
herpetic éruption, in tbose cutaueous régions to whicli tbe uerves, 
under irritation, are distributed.- Tbere are some reasons for 
believiug tbat a considérable number of cases of spontaneous 
berpes make their appearauce in conséquence of a neuritis of tbis 
kind.^ Tbe spinal gauglia also bave been found mucb altered,. 
althougb neitber the spinal cord, nor the anterior and posterior 
uerve-roots, nor even the intercostal uerves tbemselves participated 
in the lésion. A case in point bas been recently noted by Herr 
E. Wagner.^ 

An individual, aged 23, sufferiug from pulmonary pbtbisis^ 
complained, towards the close of bis existence, of an berpetic 
éruption occupying tbe régions corresponding to tbe niutb and 
tentb intercostal uerves of tbe left side. On post-mortem examina- 
tion, it was found tbat tbe bodies of the six inferior dorsal and two- 
superior lumbar vertebrœ had been attacked by caries. Tbe dura 
mater in the région corresponding to thèse vertebrae was surrounded 
externally by a thick layer of caseous pus whicb extended to tbe nerve- 
sbeatbs and spinal gauglia. Tbe dura mater itself was tbickened 
and split into two lamiuœ, especially in tbe neigbbourbood of the 
nintb, tentb, and eleventb dorsal uerve-roots. Althougb tbe 
lésions of tbe dura mater seemed as well marked on tbe right side 

1 Ciiarcot et Cotard, " Sur un cas de zona du cou avec altération des nerfs 
du plexus cervical et des ganglions correspondent s des racines spinales pos- 
térieures," 'Mémoires de la Société de Biologie.' Année 1865, p. 41. 

- Von Biirensprung, "Beitrage zur Kenntniss des Zoster," ' Arcliiv i'iir 
Anat. uud Pbysiolog.,' No. 4, 1865, and ' Canstatt's Jahresb.,' 1864, t. iv, p. 
128. 

^ ]\Iougeot, loc. cit., p. 65. 

■• U. Th. Bahrdt, " Beitrage zur /Eùologie des Herpès Zoster," Diss. Leipzig, 
1869, and E. Wagner, " Patholog. Anatomische uud Klinische Beitrage zur 
Kenntniss der Gefiisnerven." 'Arcliiv der Heilkunde,' 4e lieft, Leipzig, 1870,. 
p. 321. 



26 TROPHICAL DISORDERS FROM NBUEITIS. 

as on the left, yet the ninth, tenth, and eleventh dorsal ganglia of 
the left side only were swollen and presented appréciable altérations 
under the microscope. In thèse three ganglia the nerve-cells had 
disappeared, and in the immédiate vicinity of their vacant alveolse 
were seen ail the signs of abnormal prolifération in the connective 
tissue, carried to an advanced stage. 

In many cases of chronic spinal meningitis, accompanied by 
thickening of the dura mater, I hâve myself observed the con- 
<îomitant inflammation of the spinal nerves (in their passage through 
the méninges) give rise, not only to more or less well-marked 
atrophy of the muscular mass, but also to varions cutaneous 
€ruptions which generally presented the appearance either of zona 
or of pemphigus. In a lecture delivered at Dublin,^ M. Brown- 
Séquard had previously pointed out the existence of spécial 
«utaneous éruptions on the arms in cases of spinal meningo- 
neuritis localised in the inferior portion of the cervical région. 

Erythema, zona, muscular atrophy, and certain arthropathies 
hâve been correlated, by M. Duménil, with chronic progressive 
neuritis,^ and by M. Leudet with peripheral neuritis, consécutive 
■on asphyxia from charcoal fumes.* 

But it is, above ail, in anasthetic lepra that we encounter in 
their full development the trophical disorders which we hâve studied 
in connection with traumatic nerve-lesious. The initial morbid 
process hère consists, as we learn from the important researches of 
Herr Virchow,^ in a leprous permeuritis characterised by a spécial 
cell-proliferation, in the space between the iierve-tubes, wliich 
■détermines their slow destruction. The nerves, then, frequently 
présent in their course a spindle-shaped swelling which may some- 
times be readily recognised, during life, in régions where they lie 
superficial, as the ulnar nerve at the elbow, and thus assist in the 
diagnosis. Thèse altérations give rise, at the outset, to symptoms 
of hyperaîsthesia, and afterwards to those of ansesthesia. 

' 'Quarterly Journal of Medicine,' May, 1865 [pp. 11, 12 of spécial édition]. 

* Dunicnil, ' Contributions pour servir <\ l'histoire des paralysies périphériques, 
spécialement de la névrite." ' Gazette Hebdomadaire,' 1868. Nos. 4, 5, 6. 

•'* Leudet, ' Recherches sur les troubles des nerfs périphériques et surtout 
des vaso-moteurs, consccul ifs a l'aspliyxie par la vapeur du charbon," ' Arciiives 
Générales de Médecine,' Mai, 1865. 

* R. Virchow," Die Krankhaften Geschwiilste," ' Nerven-Lcpra,' t. ii, p. 521, 
1864-5. 



LEPHOUS TERINEURITIS. 27 

With the exception of zona, whicli I liave not seen mentioned 
anywhere, we find in thèse circumstances almost the whole séries of 
the trophical lésions which we hâve already described : a, pemphigus 
as pemjohigiis leprosus ; h, " glossy skin ;" c, muscular atrophy ; 
d, periostitis and finally necrosis. When the latter lésions attain a 
high degree of intensity we may hâve occasionally to note, you are 
aware, the loss of part of a member. This often happens without 
pain ; because, when it does occur, anœsthesia is usually présent 
{J,epra mutilans)} Some hâve attributed thèse varions accidents 
and mutilations to the effects of the ansesthesia. It should not, 
certainly, be regarded as the soie efficient cause ; for it is not only 
proved that this merely facilitâtes the intervention of external 
agencies, but also that it can be relegated to a secondary position, 
and even eliminated altogether if we take into account the cases 
given by Dr. Thomson in which there was absolutely no ausesthesia." 

We hâve hère been able only to pass rapidly in review the disor- 
ders of nutrition which resuit from irritative lésions of the peri- 
pheral nerves. In the foUowing lectures we will return to the 
subject again, but our principal object will be to describe the tro- 
phical troubles which are correlated to lésions of the brain and spinal 
cord. 

1 P. Steudener, ' Beitriige zur Pathologie der Lepra Mutilans.' Mit 3 Taf. 
Erlangeu, 1867. 

" A. S. Thomson, ' Brit. aud Por. Med.-Chir. Review,' 1854, April, p. 496, 
quoted by H. Virchow. 



LECTUEE IL 

NUTRITIVE DISOEDERS CONSECUTIVE ON NERVE-LESIONS 
{Continued). AFFECTIONS OF THE MUSCLES. NUTRITIVE 
DISORDERS CONSECUTIVE ON LESIONS OF THE SPINAL 
CORD. 

SuMMARY. — Anatomical and functional modifications occnrrlng in 
muscles iinder the injluence of lésions of tlie nerves supplt/ivg 
t/iem. Importance of electrisation as a means of diagnosis and 
prognosis. Besearc/ies of Dr. Buchenne {de Boulogne'). Ex- 
perïments : Bong persiste7ice of the electrical contractility and 
of normal nutrition qf muscles, after the section or excision of 
motor or mixed nerves in the case of animais. Pathological 
cases : Bimitmtion or speedy abolition of the electrical contrac- 
tility, folloioed hy rapid atrojphy of the muscles in cases of 
rheumatic paralysisof the facial nerve, and of irritative lésions 
of mixed nerves, lohether qf traumatic or spontaneous origin. 
Cause of apparent contradiction helween the results of cxperiment 
and thefacts of pathology . Application ofthe researches ofM. 
Brown-Séquard : Britative nerve-lesïons olone détermine the 
speedy abolition of electrical contractility , foUowed by rapid 
atrophy ofthe muscles. Experiments ofMM. Erb, Ziemssen, and 
0. IFeiss. Contusion and ligation qf nerves are irritative lésions. 
BifJ'erence of the results obtained in the exploration qf muscles 
ivhen faradisation and galvanisation are employed. The results 
of thèse neiv researches are comparable with the facts of himan 
pathology ; they do not weahen the 2^roposition of M. Broivn- 
Scqnard. 

Trophic disorders consécutive on lésions of the spinal cord. 
Considered with regard to their influence on the nutrition of the 
rauscles thèse lésions constituie two %oell-defined group)S. 

First group : lésions of the cord having no direct influence on 
muscular nutrition : a, lésions in circumscribed spots affecting 
the grey substance to but a slight extent vertical ly, e. g. partial 



AFFECTIONS OF THE MUSCLES. 29 

mi/eUfis, timours, PoU's disease ; h, extemive fasclcnlated 
lésions of the wJiite posterior or antero -latéral columns, wiihont 
tlie grey matter participating ; e.g. primitive or sccomlary 
sclerosis qf the posterior, antero-lateral columns, S^c. 

Second group : Usions of the spinal cord which influence, more 
or less rapidhj, the nutrition of the muscles : a, fasciculated or 
circumscribed lésions which affect the anterior cornua qf the 
grey matter to a certain extent, in Iteight ; central myelitis, 
hœmatomyelia, 8fc. — è, irritative lésions of the large nerve-cells 
of the anterior cornua with or loithout participation on the part 
of the white fasciculi : infantile spinal paralysis, spinal para- 
lysis qfadults, gênerai spinal paralyses {Duchenne de Boulogne), 
progressive muscular atropihy, Sfc. Predotninant inflioence 
of lésions of the grey matter in the production of trophical 
trouLles of the muscles. Thèse facts can le interpreted hy 
means of Brown-Séiiuard' s proposition. 

Gentlemen. — In the preceding lecture, whilst sketching the liis- 
tory of nutritive troubles consécutive on nerve-lesious, I purposely 
avoided dwelling on the anatomical or functional modifications to be 
found in muscles under the influence of thèse lésions. I desired to 
reserve this question for a spécial study. In reality, as you will 
soon acknowledge, this is a subject surrounded by difficulties of ail 
kinds and is even now the object of a thousand controversies. 

You are aware of the great progress which has been made in the 
clinical history of paralytic affections, under the influence of the 
labours of Dr. Duchenue (de Boulogne). But you know also, with- 
out doubt, that a considérable number of the facts discovered by 
this eminent pathologist seem to be in flagrant contradiction with the 
results obtained by physiologists in their experiments upon animais. 

What is the reason of this discordance ? In what direction are 
we to look for means of eifecting a reconciliation between them ? 
Thèse are desiderata, which I do not undertake to answer in a 
manner perfectly satisfactory on every point. Yet I must not recoil 
from before the difïîculty ; I am bound, at least, to examine it. To be 
candid, I feel some répugnance to treat a question, where the results 
of the electrical exploration of nerves and muscles must be con- 
tinually referred to, in the présence of men who hâve made so pro- 
found a study of this mode of examination. But if they meet with 
criticism, I hope they will accord me their gênerons indulgence. 



30 EXPEEIMENTS ON ANIMALS. 

I. 

We may say, in a gênerai manner, that electro-diagnosis, if I 
may invent a term^ anuounces and demonstrates (in certain patho- 
logical cases where a somewhat intense lésion of a mixed or motor 
nerve has taken place), the rapid and great diminution, it may be 
even the total disappearance of that property which is known by 
the uame of electrical contractility. Yet, on the other hand, experi- 
ments on animais appear to show that, after lésions inflicted on 
nerves, the muscles préserve for a comparatively long time, even 
indefinitely, according to some authors, the property of contracting 
under the stimulus of electricity. 

You will readily understand the interest which, from our point of 
view, belongs to the récognition and study of facts of this kind. It 
suffices to remind you that the enfeeblement and, à fortiori, the 
loss of electrical contractility, rapidly ensuing on the lésion of a 
nerve, are, as clinical observation has frequently shown, the first 
term of a séries of phenomena which, if the physician do not inter- 
vene, almost necessarily entail, in certain cases, the more or less 
complète atrophy of the muscle and sometimes the total loss of its 
functions. 

In order to set ont in a clearer light the discordance to which 
I hâve called your attention, allow me, gentlemen, briefly to recall 
the expérimental facts in question : 

A. It was proposed, in thèse experiments, to seek ont the modi- 
fications which take place in the properties of muscles and in their 
anatomical structure, after the section or excision of the nerves 
supplying them. Experiments abound : they hâve been made and 
repeated by MM. Longet, Schiff, Brown-Séquard, Vulpian, and it 
must be added that the results which they hâve given appear, at 
least as regards essential points, to be quite concordant. The 
following are the principal incidents of thèse experiments that seem 
to call for notice hère. 

When a nerve has undergone section or partial excision, its peri- 
pheral extremity begins, from the fifth to the sixth day after the 
opération, to undergo even in its finest ramifications a séries of 
altérations whose ultimate conséquence is the disappearance of the 
meduUary cylinder, whilst the axial filament appears, on the contrary, 
to persist almost indefinitely.^ 

> Professor Schiff has showu that, iu cases of nerve-degeneration following 



ELECTEICAL CONTE ACTILITY. 31 

On tlie otlier hand^ from the fourth day, that is to say, before 
ev^en the lésions of the degeneration are appréciable, the nerve 
(accordingto M. Yulpian, loc. cit., p. 235) is found to hâve alreadj 
lost the faculty of being excitcd by différent agencies, and in par- 
ticular by the electrical stimulus. There is no différence of opinion 
in référence to this point. With respect to the muscle; it does not 
présent, at first, any modification whatever of the electrical con- 
tractility. The decrease, and still more the utter loss of this pro- 
perty, if they do ensue, are never produced until after a considérable 
lapse of time, and very slowly. Hère, again, there is no divergence 
of opinion. If some physiologists state they hâve seen the electrical 
contractility lesseued, or eveu lost, at from six to twelve weeks after 
the section of a mixed nerve, M. Schiff lias, on the contrary, under 

on section tbe axis cyliuders persist, cnnlrary to wliat M. Waller had asserted ; 
he found tlie filaments in tlie uerve-fîbres of nerves of mammalia, wliich had 
becn eut iive niouths previously. "We Lave also recognised," says M. Vul- 
pian ('Leçons sur la Physiologie du Système Nerveux,' 1866, p. 236), "the 
existence of this axial filament at the end of more than six nionths. It appears 
to me very probable that it persists beyond this space." 

Since the above was written, M. Ranvier (' Comptes Rendus de l'Académie 
des Sciences,' 1872) published the resuit of his researches on nerve-degenera- 
tion, and demonstrated the destruction of the axis-cylinder. Havino- had 
opportunities of examining his préparations whilst studying in his Laboratory, 
I may be allowed to state that the contiuuity of the axis-cylinder was plainly 
shown to be broken, at intervais ; it has been objected, in a German periodical, 
that this might be an appearance due to the reageut employed, but the alléga- 
tion is invalid, seeing that the production of the resuit does not dépend upon 
the use of one reageut. The foUowing is a brief summary of M. Ranvier's 
conclusions. The interanuular segment constitutes an histological unit. It is 
formed by Schwann's sheath, lined by a layer of protoplasm coutaining a lenticu- 
lar nucleus ; beneath is the meduUary sheath, through which passes the axis cylin- 
der, whieh is probably enveloped in a protoplasmic layer, reflected at the 
annular constrictions which terminate the segment. Twenty-four hours after 
section of the isehiatic or pneumo-gastric nerve, in a rabbit, the nuclei in ques- 
tion are slightly swollen, and the outer protoplasmic layer becomes granular. 
Forty-eight hours after section, the tuméfaction of the nucleus is greater, and 
the protoplasmic layer forms lumps that jut into the raedullary matter, and give 
it an irregular shape. After the seventy-second hour, the nucleus is so swollen 
as to fill nearly the width of the tube — there, the medullary matter, completely 
interruptcd, leaves a space occupied by a mass of protoplasm sprinkled with 
fatty granulations, and enclosing the nucleus. The protoplasm is also swollen 
at différent points and has driven back the medullary sheath, reducing it, to a 
mère thread, or completely dividing it. Towards the end of the third day the 
axis-cylinder is eut across, opposite each nucleus. This fact explains the loss 



■32 ELECTEICAL CONTEACTILITY. 

some circuin stances found it perfectly preserved at the end of four- 
teen months.^ The sarae stateinent holds good if the section be 
made of an exclusively motor nerve. M. Longet had already shown 
that, whilst the motricity of nerve is, as we hâve said, entirely 
aboHshed four days after section, the muscuhir irritability, in so 
far as the facial nerve is concerned, persists in the corresponding 
muscles for over three months.^ After excision or section of the 
facial nerve, MM. Brown-Séquard and Martin-Magron hâve seen 
the irritability of the facial muscles survive, in the case of guinea- 
pig and rabbit, for nearly two years.^ M. Vulpian lias also borne 
testimony to precisely the same effect,'^ About the year 1847, in the 
laboratory of my excellent master Martin-]\Iagron, whilst working in 
a field, which my sensitiveness in référence to animal sufFeriiig soon 
caused me to abandon, I was able personally to observe the almost 

of excito-niotricity iu a iierve, which superveues at about tliis daic at'ter sec- 
tion, accordiiiQ,' to Loii2fet. Froin the fourtli day, tlie degeneratiou goes on 
increasiug, and ou the sixth the medullary matter is reduced to minute frag- 
ments, whilst the protoplasm which lias become very abundant contains a 
considérable uumber of fatty granulations and its nuclei bave niultiplied. 
From the seventeenth to the twentieth day the prolifération of nuclei does not 
actively proceed. Wheu the nerve is examined iu transverse section very few 
axis-oylinders are found in the tubes on the twentieth day. Thèse remarks 
refer to the peripheral end of the divided nerve : the process of degeneration 
in the central eud is very différent. The medullary matter is decomposed into 
fine granulations, accreted in oval clustcrs, the iniclei inultiply aud the proto- 
plasm augments, without hcwever segmenting the medullary matter, by jutting 
•masses. On Ihe coutrary, the nuclei are flattened l)etwecn theaxis-cyliudcr aud 
Schwann's sheath. The axis-cylinder itself persists, its connection with the 
nerve -centres being preserved it energetically rcsists the destructive action of 
the nuclei and protoplasm. Hence, M. Ilanvier lias corne to the conclusion that 
the altérations undergone by nerve-tubes, in the peripheral portion of a divided 
nerve, which are commonly called degenerative hâve not this charactcr iu so far 
as the cellular éléments of the nerve-tube are concerned, for this, ou tiic con- 
trary, displays phenomcua of formative activity which hâve an opposite meaniiig 
to that of degeneratiou, iu the language of aiiatomo-pathologists (Cl. Siger- 
son). 

' Schiir, ' Lclubuch dcr Physiologie des Menschcn,' 1858-59, p. 18: M. 
Schilf asserts that he saw, in two cases, an excitability of the muscles jjcrsist 
for fourtecn moutlis after section of the corresponding nerves, the hypoglossal 
nerve had been divided iu onc case, and the ischiatic iu the other. 

- Longet, ' Anatomie et Physiologie du Système Nerveux,' t. i, p. Gt„ [842. 

^ Brown-Sérpiard, ' P>ullctins de la Société Philomathique,' 1847, pp. 74 et 88, 
'Bulletins de la Société de iiiologic,' t. iii, 1851, p. loi. 

■• Vulpian, loc. cU., p. 235. 



EXPEKIMENTS. 35 

indefinite persistence of electrical contractilit}^ iii the correspondiug 
muscles, after the excision of the facial nerve. 

The resuit is so palpable^ striking, and easy of observation that 
most physiologists hâve corne, if I mistake not, to question whetlier 
muscular irritability ever disappears completely in conséquence of 
the section or excision of the nerves, They concède, at most, that 
in such a case there may be produced, in the course of time, a less or 
greater degree ofenfeeblement of the contractile property of the mus- 
cles. Almost ail of them point out that if the electrical stimulation 
sometimes becomes powerless to détermine contraction of the muscles, 
yet this will be produced under the influence of mechanical irri- 
tation. 

It was to be supposed that the nutritive or trophical modifications 
corresponding to thèse functional changes would likewise be very 
slowly produced and but slightly apparent. This, in fact, is what 
seeras to take place. Most authors appear to agrée in recognising 
that the atrophy of the muscle and its histological degeneration 
supervene only when a very loug time has elapsed after the nerve- 
section. According to M. Longet,^ when, three months after divi- 
sion of the facial nerve, a post-mortem examination was made 
scarcely any traces of atrophy, however slight, were to be observed. 
But he doubtless refers to an examination made with the naked eye. 
M. Schiff' asserts that, when the paralysis consécutive on a nerve- 
section is of old standing, the muscles show a certain amount of 
wasting. It is probable that a certain number of muscular fasciculi 
waste away and disappear. In most cases, the microscope reveals 
that a considérable number of thèse fasciculi undergo fatty degene- 
ration and présent an accumulation of fat in their interspaces.- M. 
Yulpian's researches hâve given analogous results, but, according to 
this author, the fatty degeneration of the muscular fibre is olten 
completely absent.^ 

Before comparing the facts of pathology with the results of expe- 

' Longet, loc. cit., p. 63. 

2 Schiff, loc. cit., p. 175. 

^ Vulpian, loc. cit., iu cases of paralysis, consécutive ou nerve-sectiou, 
besides the atrophy of primitive nerve-fibres wbich is produced in the course 
of time, M. Vulpian lias long since remarked the prolifération of the nuclei of 
the sarcolemma, and some other indicia of iuflammatory action. This is a 
very interesting fact, since iioted by other observers, and one to which we shall 
hâve occasion again to refer (sec note - ivfrà, pp. 36 7). 

3 



34. PATHOLOGICAL FACTS. 

riinents on animais, it is important to clearly understand tlie condi- 
tions under whicli the latter hâve been conducted. In the first 
place, the physiologist makes a section or excision of the muscular 
nerves ; in the second place, he resorts to direct electrical stimu- 
lation, applied to the denuded nerve or muscle. He makes use of 
galvanism, almost exclusively, as an agent of exploration and takes 
no heed of the différence which may exist, as to their action on 
nerve-fibre or muscular fascicle, between the excitation obtained by 
means of induction (or interrupted) currents, and that determined 
by the galvanic (or continued) carrent. Thèse are circumstances 
which it is important to note, especially in relation to the experi- 
ments which I shall call old, although they do not yet date from a 
very remote period. We shall see afterwards that quite récent re- 
searches, in which the action of both currents bas been comparatively 
studied, bave yielded results apparently différent in some respects 
from thosc furnished by former experiments. 

B. Let us now take the field of human pathology into considéra- 
tion. The facts which it offers us, are connected with lésions of 
mixed or motor nerves which either take place spontaneously or 
supervene in conséquence of a wound. 

In the first place, we will describe the phenomena observed in 
cases of peripheral paralysis of the facial nerve and, particularly, 
where that paralysis is due to the influence of cold (rheumatismal 
paralysis a frigoré), M. Duchenne (de Boulogne) has showu, as 
y ou are aware, that in such a case, the electrical contractility of the 
muscles of the face is remarkably Icssened and even appears some- 
times to be extinct,^ before the end of the first week. You will 
remark that between this period of seven days, which according to 
M. Duchenne may mark the beginning of the decrease of electrical 
contractility in rheumatismal paralysis of the facial nerve, and the 
term assigned by some physiologists for the persistence of the same 
property in animais, after nerve-section, the différence is great. 
Nevertheless, researches again and again renewed hâve demonstrated 
the perfect accuracy of M. Duchenne^s assertion. Quite recently 
also, in a case of rheumatismal paralysis of the facial nerve, Dr. Erb, 
having had an opportunity of following the course of the symptoms 
from day to day, noted that, on the ninth day, the electrical contrac- 

' Duchenne (de Boulogiu;), ' .Elcctrisation localisée,' 2C cdilioii, 1861, p. 669. 



ALTERATION OP THE MUSCLES. 35 

tility had already dimiiiislied to a considérable extent.i In a similar 
case^ recorded by Dr. Onimus when, eiglit days after the invasion 
of tlie diseasc, the induction current was resorted to, the paralysed 
muscles did not présent the slightest contraction. 2 

The same fact is usually remarked in cases of peripheral paralysis 
of the facial nerve, resulting froni causes other than the influence of 
cold, and likewise in those of traumatic paralysis of nerves of ex- 
tremities. The last-mentioned generally folio ws, as you know, on 
abrupt compression, contusion, or concussion of a mixed nerve, as a 
conséquence, for instance, of scapulo-humeral luxations. The elec- 
trical contractility lias been many times found very notably lessened 
from the tenth, and even from the fifth day in the muscles, struck 
with paralysis, after such and similar accidents.^ 

Clinical observation demonstrates,you must know, that, as a gênerai 
rule, the muscles which thus présent a prompt diminution and, above 
ail, a prompt disappearauce of electrical contractility are soon 
affected by atrophy which sometimes becomes very rapidly manifest, 
especially in the case of paralysed limbs. It would be highly 
interesting to study, in the several phases of their develop- 
ment, the histological altérations to which this rapid w^asting of 
muscular masses is assignable ; but this is a subject in relation to 
which we possess as yet but little exact information. It seems, 
however, to follow from some researches and particularly from a 
case recorded in détail by Dr. Erb, that thèse lésions hâve nothing 
in common with passive fatty degeneration, pure and simple, such 
as we find in muscles that hâve been long condemned to inactivity. 
They appear on the contrary to présent the clearest characteristics 
of an inflammatory proccss, to wit, a more or less ixiarked hyper- 
plasia of the interstitial connective tissue, recalling to some extent 
what we see in cirrhosis, and a multiplication of the nuclei of the 
sarcolemma. Concurrently with the development of thèse altéra- 
tions, the muscular fibres undergo a very évident decrease in their 
transverse diameter, but they préserve, in most instances, their 
striated appearance. The fatty granular degeneration of the mus- 

1 W. Erb, ' Zur Pathologie uud Pathologischen Anatomie Periplieriscber 
Paralyseii,' iii 'Deutscli. Arcliiv/ t. iv, 1868, p. 539. Gradolfs case. 

2 'Gazette des Hôpitaux,' 30 Juiu, 1870, p. 298. 

3 Duclienne de Boulogne, loc. cit. Obs., p. 191, Paralysie suite de luxation 
scapulo-liuméral. Obs., p. 193, Paralysie suite de contusion du nerf cubital. 



36 ALTERATION OF THE MUSCLES. 

cular fibres is rarely met witli, in thèse cases^ and appears to be alto- 
gether accidentai.^ 

It is clear that if, in the muscular atrophy which pliysiologists 
obtain, in tlie long run, by section or excision of the nerve, the his- 
tological lésion were always fatty degeneration without trace of irri- 
tative action the contrast would be extremely manifest. But un- 
fortunately for the simphcity of things, we see that this, perhaps, is 
not the case.- 

' The following is an abridgement of tlie observation rccorded by Dr. Erb 
in Lis interesting memoir : 

Peter Schmieg, aged 22 years, suffers from pulmonary ])litliisis in its last 
stage, and likewise lias caries of tlie petrous portion and niastoid process. An ab- 
scess bas biirst in the vicinity of the latter. On tlie 22nd of March, 1867, almost 
complète paralysis of the left facial nerve occurs. The paralysis is particularly 
évident in the frontal muscle. Investigation of the electrical contractility 
having been made, first ou March 24th (the second day of the disorder), next on 
the 3rd April (i2th day), by means of faradisation, it was found normal on 
both dates. On the lyth April (26th day), for the first time, it is ascertained 
that the frontal and zygomatic muscles of the left side contract but feebly 
under faradaic stimulation. On the 3oth April (39th day), faradisation no 
longer causes contraction in thèse muscles, the other muscles of the left side 
of the face respond but feebly to the stimulus. Death supervenes May 2nd 
(40th day). 

Post-mortem. — The trunk of the facial nerve bounds an abscess wliich bas- 
opened beliind the car : it is denuded to a certain exteut. The uerve-trunk. 
is envelojjcd on every side by a mass of indurated connective tissue. This 
conuective envelope closely adhères to the external nerve-sheath of tiie nerve, 
•which, however, is still free within it. To the naked eye, the branches of the 
facial nerve offer no perceptible modifications ; on the other hand, the left 
frontal muscle is pale, flabby, and thin. Where the nerve-trunk is enveloped 
by the mass of connective tissue tliere is found, interposed between the uerve- 
fibres, a quantity of fibrous connective tissue, with numerous oval nuclei,. 
faintly granular. A certain uumber of the nerve-iibres themselves présent the 
several stages of fatty degeneration. Many of the fibres hâve preserved their 
normal character. Some of the filaments supplying the frontal muscle scarcely 
show any but degenerated nerve-ûbres ; other filaments beloiiging ap- 
parently to the trifacial bave ail their fibres in a normal condition. The left 
frontal muscle is greatly altered : thick septa of newly formed connective 
tissue are obscrved, interposed between the primitive muscular fasciculi. The 
latter are much rcduccd in bulk, and contain a large quantity of nuclei. On 
most of the atrophied fibrils the striation romains distinct; on others it is. 
scarcely perceptible. A certain numbcr of the primitive (ultimate) bundles 
présent the characteristics of waxy altération, but none of fatty granular 
degeneration (W. Erb, loc. cit., 'Deutscli. Arciiiv,' Bd. 5, p. 44, 1866). 

- We reserve the right of returning upon this délicate point in the course 



APPARENT CONTRADICTION. 37 

It follows, in short, from the parallel wliich we hâve placed bc- 
'ïore you that clinical facts, thoiigh most carefully observed, are or 
at least appear to be in formai opposition to expérimental facts, 
likewise collectée! by the strictest methods. We should endeavour 
'to penetrate the reasou of this discordance. Let us first seek if it 
can be found in the différence betweeu the conditions of observation 
in which the physiologist and the physician take their stand. 

The first thing which requires to be distinctly brought ont relates 
io the mode of exploration. The pathologist finds himself forbidden 
to explore the muscle, except through the skin, whilst the physiolo- 
gist, as we hâve already remarked, can act under more favorable 
conditions, since he may apply the électrodes directly to the nerve 
or muscle. It miglit be anticipated that, where a certain degree of 

of OUI- lectures. At présent, let it sutSce to note that irritative lésions of 
muscles, quite similar to tliose which liavc been described, hâve beeu recently 
recorded by very compétent observers, in several animais, after section and 
•excision of niixed or purely motor nerves, that is to say, outside the conditions 
which commonly cause irritative nerve-lesions. Thus, wheu he had eut out a 
portion of the ischiatic nerve, Dr. Mantegazza (' Histologisch-Veranderungeii 
nach der Nervendurchschneiduug,' in 'Schmidt's Jahresb.,' p. 148, t. 136, 
1857, and ' Gaz. Lomb.,' p. 18, 1867) found, after the thirtieth day, the 
■ muscles pale, the connective tissue iuterposed between the primitive (or ulti- 
mate) fasciculi evidently hypertrophicd, the fasciculi (theniselves diminished ia 
bulk) presenting a mauifest multiplication of the nuclei of their sarcolemma, 
but still preserving their transversal striœ. A considérable number of the 
fasciculi showed a granular aspect, but the granulations dissolved in acetic 
acid. Professor Vulpian lias, likewise, met with identical altérations in the 
lingual muscles of a dog, fifty days after the avulsion of the central part of the 
hypoglossal ncrvc ('Archives de Physiologie,' t. ii, p. 577, 1869). ïhc absence 
of fatty degeneration in the primitive fasciculi, the atrophy of thèse flbres 
with persistence of the transversal striation, and the prolifération of the sarco- 
lemma-nuclei, liave also been observed by M. Vulpian (hc. clL, p. 559^) in the 
muscles of the human leg, in a case of résection of a segment of the ischiatic nerve 
datiug from fivc months before. That being the case, we are led to admit that 
complète sections, excisions, and avulsions of nerves do occasionally détermine 
irritative lésions in them : or else, — if furthcr observations should prove ihe 
fact recorded by MM. Mantegazza and Vulpian to be constant, — that the 
■muscular lésions which foUow passive lésions of motor or mixed nerves are not 
essentially différent, histologically considered, from those which supcrvene on 
irritative lésions of Ihose nerves. If the facts should support the second 
hypothesis thcre would still be occasion, we thiuk, to différent iate, in spitc of 
so mauy analogies, between muscular altérations connected with funclional 
iuertia and those conséquent on nerve-irritation. It appears, in fact, to be 
.demonstrated tiiat the latter supcrvene vv'ith much greatcr rapidity, and are 



38 INFLUENCE OF EXPLOEATION-METHODS. 

diminution of tlie electrical contractility obtains, direct ap])lication 
would be still capable of determining contractions, when (indirect) 
exploration through the skin would, perbaps, be powerless, or would 
at most provoke very feeble contractions. Experimentshave justified 
tbe accuracy of tbis anticipation. Tbus, in a case of clubfoot, witli 
fatty degeneration of tbe muscles, Valeutin, after tbe opération, re- 
marked contractions, of a feeble cbaracter indeed, take place in one 
of tbe most tbrougbly altered muscles, under tbe influence of 
direct stimulation.i In tbis case, if we may judge by analogy, ex- 

precedcd and accompanied by more or less marked modifications of electrical 
contractility, wliicli do not show themselves iu the former with the same 
characteristics, and only make their appearance at the end of a comparatively 
very long lapse of time. 

It is to be desired that a séries of researches were instituted with the spécial 
object of elucidating the question which has just been raised. There does. 
indeed, already exist a certain nuniber of facts tending to demonstrate that 
immobilisation may, by itself aloue, aud outside of ail nervous influence, 
provoke in certain organs and tissues, ail tbe characteristics of inflammatory 
action. I shall cite but one example : we know the articular affections, de- 
scribed by MM. Tessier and Bonnet, which supervene when limbs are con- 
demned to immobility, as the treatment of certain cases of fractui'e requires. 
Quite rccently, M. Menzel undertook a séries of experiments, which consisted 
in immobilising, by plaster of Paris bandages, a certain number of articulations 
of dogs and rabbits. Now, from the fîfteentli day, the synovial membrane was 
found to be vividly injected and tumefied, the articular cavity contained red 
corpuscles, white corpuscles, and epithelial cells ; fînally, the cells of the 
diarlhrodial cartilage were found to be the seat of well-marked prolifération 
('Gazette Médicale de Strasbourg,' No. 5, 1871). Thèse researches deserve 
to be followed out and applied to the study of the modifications which may 
affeet différent parts of a limb under the influence of functional inertia, con- 
tinued for a less or greater length of time. 

' Valentin, ' Versuch. eiuer Physiologischen Pathologie der Nerven.' Leip- 
zic und ïïeidelberg, 1864, 2e abtheil, p. 42. 

An expcriment of great interest, from tins point of view, was made by my 
(late) master, Dr. Duchenne (de Boulogne), to whom the priority of investiga- 
tion seems to belong. He relates (' Electrisation localisée,' p. 40), that haviug 
found a portion of the vastus externus denuded in tlie case of a wounded 
patient (Salle St. Bernard, Hôtel Dieu), lie applied a dry électrode to the 
denuded portion of tlie muscle. The contraction which followed was accom- 
panied by a dull sensation, characteristic of clcctro-muscular contraction. He 
next placed the same électrodes on the unharmed skin over the same muscle, 
and only produccd a burning sensation, without muscular contraction. This 
rcsult, conscquently, givcs cmphatic support so far to the statcmcnt in the 
above lecture. But Dr. Duchenne (de Boulogne) proceeds to observe that 
haviug replaced the mctallic électrodes by moist sponges, enclosed in excitator- 



EXPEllIMENTS. 39 

ploration througli tlie skin would ])robably hâve given no resuit. 
Some facts, borrowecl from tlie domain of expérimental pliysi- 
ology, furnisli similar évidence. 

When^ in tlie case of a rabbit whose right facial nerve liad been 
eut across about a moiith before, electricity was applied tlirough the 
shaven and moistened skin, to the right facial muscles, no apparent 
efl'ect was produced, whilst extremely strong contractions were 
caused, when the homologous région of the left side vvas acted on. 
But, when the muscles were denuded on the right side, where the 
ncrvc was eut, and electricity applied to them, very marked con- 
tractions were produced. Agaiu, a segment of the left external 
popliteal nerve, about two inches in lengtli, was excised, the animal, 
this time, being a vigorous horse. One month after the opération, the 
hair was shaven off the antero-external surface of each leg, and the 
électrodes of a pile were a])plied. On the healthy leg, energetic 
contractions followed the application; but no contraction was 
caused in the other, when the same test was attempted. Then, the 
paralysed muscles were denuded and the stimulus was applied to 
them directly, the minimum power of the instrument being em- 
ployed. Lively contractions were the conséquence.^ A considérable 
number of similar examples could, doubtless, be collected without 
difïiculty. Hence, it is demonstrated that exploration through the 
skin can only supply approximative data, and that it does not re- 
veal the real state of the electrical contractility, but such as they are 
the data furnished are not the less exact and must be considered as 
of the highest importance, for it is impossible not to acknowledge 
that the great decrease or apparent loss of contractiUty, detected 

cylinders, aud placed thèse on the skin, he obtained contraction with the same 
dull characteristic sensation, previously produced by application of the 
metallic électrodes to the denuded muscle. As this experiment was not made 
with a view to détermine the exact différence caused by the interposition of 
the skin, the latter statemeut does not couflict with any given in the text ; 
whilst the circumstances of the two experiments amply justify the view taken 
by Professor Charcot. It is logical to suppose that the différence of electrical 
action, due to the interposition of the skin, which was noted in the first experi- 
ment, would stili remaiu, though to a very much less extent, in the second 
experiment, and would hâve been probably detected by Dr. Duchenne (de 
Boulogne) had his investigation been conducted with the object of ascertaiuing 
the précise araount of obstruction given by the skin. The experiment of 
Valentin helps to fulfil this desideratum (S.). 

' Experiment of M. Chauvcau, inMagniu : 'Thèse de Paris,' p. 21, 1866. 



40 FAEADISATION AND GALVANISATION. 

by exploration through the skin, corresponds to a diminution or at 
least to a very great modification of this property. 

Another question which requires to be considered relates to the 
nature of the electrical agency employed in exploration. Galvani- 
sation^ as I mentioned just now, has been almost the only means 
made use of in the experiments concerning nerve-sections in animais, 
whiist in clinical practice, following Dr. Duchenne's method^ the 
work of investigation has been pursued until lately, by means of 
faradisation^ exclusively. Now, it follows from researches made a 
îew years ago in Germany, and recently taken up in France, that 
galvanisation has often power to cause muscular contractions even 
where faradisation seemed to indicate an absolute loss of electrical 
contractility . 

This fact, recorded for the first time by Baierlacher, in 1859/ in 
a case of facial paralysis, has been remarked since, either under the 
same circumstances, or in différent cases of paralysis cansequent on 
traumatic lésions of mixed nerves, by Schultz,^ Brenner,^ Ziemssen,* 
Eosenthal,^ Meyer,*^ — by Brûckner,''' in pseudo-hypertrophie para- 
lysis, and, finally, by Hammond in infantile paralysis. From 
this it will be seen that galvanisation may still reveal contrac- 
tile power présent in many cases of paralysis, whether arising from 
rheumatic or traumatic causes, when an exploration, conducted 
by faradisation only, would indicate a profound altération of elec- 
trical contractility. But, even though this is the case, the character 
drawn from the abolition or rapid decrease of faradaic contraciilïty 
would subsist, not the less, in ail its value : it will still allow us to 
maintain the contrast between paralyses from nerve-lesions, such as 
clinical practice usually présents, and paralyses determined in ani- 
mais by nerve- section, since the character in question is déficient in 
the latter cases. 

We bave now to examine if the nerve-lesions which provoke a 
prompt modilication of the electrical contractility, soon foUowed by 
muscular atrophy, can be assimilated without réservation, as some 

1 Baïerlaclier, 'Bayz. iirztl. Inlelligcnzblatt,' 1869. 

2 Schultz, 'Wiener mcdic. Woclicusclir.,' No. 27, 1860. 

' Grûnewaldt, ' Ueber die Lalimuugcn dos Nerv. l'acialis.' Pot. nicd. Ztscb., 
Bd. iii, p. 321 ff., 1862. 

* Ziemssen, 'Elektricitat in der Med./ 2 aufl., 1864. 

* Rosentlial, ' Elcktrotlicrapie/ 2 aufl., 1869. 

^ Mcyer, 'Die Elektricitiit,' etc., 2 aufl,, i86r. 
^ Briickiier, ' Dcutscli Klinik,' No. 30, 186,1^. 



NERVE-LESIONS. 41 

authors appear to believe^ to nerve-sections, as performed upon 
animais. In realitj, gentlemen, this is not at ail the case, and, if I 
err not, it is in this circumstance that we must seek the knot of the 
disputed question. We may say, speaking generally, that the sec- 
tions or excisions of nerves do not usually set up, in thèse, any 
reactive process. The degeneration of the fibres of the distal end, 
whicli follows the opération as a necessary conséquence, may be con- 
sidered, supposing no complication to interfère, as a purely passive 
process. The muscles supplied by the divided nerves are necessarily 
smitten witli functional iuertia ; but they do not appear to undergo 
any otlier changes than those which, in the course of tirae, resuit 
from inaction.^ 

Very différent are the affections of the nerves to which are as- 
signable, in man, the disorders that constitute the object of our 
study. They arise almost always wlien of traumatic origin, as we 
hâve said, under the influence of causes such as concussion, contu- 
sion, compression, imperfect division, — ail eminently calculated to 
provoke in the difierent tissues which enter into the composition of 
a nerve, the development of irritative action. In fact, it is not 
rare, in cases of this kind, that muscular wasting of a rapid type, 
galloping atrophy as it were, announced almost from the outset by 
the diminution and loss of the faradaic contractility, should be pre- 
ceded, accompanied, or followed — vvliere a mixed nerve is concerned 
— by more or less acute pains, or by abnormal sensations, ail being 
indicia of the irritation set up in the sensitive nerve-fibres.- To thèse 
pains may often be added the appearance of trophical skin-disorders, 
pemphigoid éruptions, glossy skin, herpès — which we hâve come to 
recognise as one species of the effects of irritative lésions of the 
cutaueous nerves, and which are never seen, in any shape or form, 
after simple sections of the nerve-trunks.^ The phenomena of 
spontaneously developed diseases lead to identical conclusions. 
Sometimes caries of the petrous bone exists, the trunk of the facial 

' See ante, note -, pp. 36-37. 

^ Ducheniie (de Boiilo_2;ne), loc. cit., Obs. ix, x. 

3 To mention one example, see the caic recently rcported by Dr. Constantia 
Paul ('Société de Thérapeutique,' Séance du 7 Mai, 1871,111 ' Gazette Médi- 
cale,' p. 257, No, 25, 1871). One of the most remarkable dérangements of 
nutrition produced by nerve-lesions is the emaciation or atrophy of the muscles 
supplied by thèse nerves. This atrophy may exist alone, or may be associated 
with other nutritive disorders of the same kiud occupying the skia and its 
appendages (Mitchel, Morehouse, and Keen, ' Gunshot Wounds,' &c., p. 69). 



42 lERITATIVE NERVE-LESIONS. 

nerve lies in the pus, where it is corapletely surrounded, as in the 
case wliicli Dr. Erb records, by a deuse slieath of newly formed con- 
iiective tissue.i At other times, the nerve is compressed by a slowly 
develo])ed tumour whicli mnst irritate, for some space of time, tbe 
iiervous fibres before completely crushing them — nay, tliere is none 
of tbe séries, even including so-called rheumatismal paralysis, or 
paralysis a fngore (tbough hère we, as yet, lack positive évidence) 
which should not apparently be attributed to inflammation of the 
connective sheathing of the nerve-trnnk.3 I am not unaware that 
complète nerve-sections are somewhat frequently met witli in sur- 
gical praetice : I know also that in such cases, you may see atrophy 
of tlie muscles and loss of electrical contractility supervene. But 
I do not believe that many cases of this kind can be adduced in 
which an observer bas noted/y-om the first daij s diminution or lossqf 
faradaic contractility and from the first loeeks, atrophy and degene- 
ration of the muscles. Although I bave made some researches on 
this subject I bave not found up to the présent any cases unques- 
tionably possessing this characteristic. 

We are thus induced, gentlemen, to bave recourse hère also to 
the luminous distinction proposed by M. Brown-Séquard : — nerve- 
irritation alone is capable of determinitig rapid and early (drophy 
of the muscles, preceded hy decrease or disappearance of faradaic 
contractility . Complète nerve-division does not induce atrophy and 
loss of electrical reaction until after an incomi'tarahly greater lapse of 
time, as in the case of prolonged inaction. 

That being concedcd, we liave now to seck in what manner — an 
irritative nerve-lesion being given the existence of which bas been 
recognised — we can dérive from it, as a more or less direct consé- 
quence, the rapid loss of electrical contractility, the early atrophy 
of the muscles, and, in a Avord, tbe whole séries of phenomena which 
clinical observation discerns in the cases that engage our attention. 

The enfeeblement or loss of contractility is, you are aware, next 
to motor paralysis (which in the vast majority of instances heads 
the ])roces3ion), the first fact which we take note of, in such circum- 
stances. Some authors seem to see, in this symptom, a very simple 
conséquence of the loss of excitability in the nerve, supervening 

' See P. Broiiardel, 'Lésions du roclier, carie, nécrose, et des complications 
qui en sont la conséquence/ Extrait du ' Bulletin de la Société 7\.natomique,' 
Paris, 1867. 

^ F. Niemeyer, ' Lebrbuch der S|)ec. Pathologie und Thérapie,' ye aufl., 
2e VA., p. 365. 



IRRITATIVE XERVE-LESIONS. 43^ 

liere at au early period (about tlie fifth day), as in tlic case of 
nerve-sections, and assignable to degeneration of the medullary 
sheaths, beyond tlie injured part. It appears certain that the con- 
tractions of the muscles, caused by electricity, are more marked 
when we can act upon them through the médium of the nerves, 
than where the stimulus, in conséquence of the distinction of the 
nerve-filaments, can no longer bear upon the contractile substance 
itself. But however this may be, if the opinion to whicli we refer 
were well founded, the marked enfeeblement or apparent abolition of 
the electrical contractility superveuiug some days after the opéra- 
tion should be a constant fact, after nerve-sections; since in such 
cases the distal end of the nerve always loses its excitability at the 
end of tive or six days. Now, we know that this is not the case. 
On the other hand, it is by no meaus proved that nerve-lesions 
which induce early loss of electrical contractility are always suffi- 
ciently intense to completely interrupt the continuity of the nerve- 
fibres and détermine tlie destruction of the medullary cylinder. A 
certain number uf facts might, in truth, be cited which tend to de- 
monstrate that the continuity of the nerve persists, at least to some- 
exteut, even after lésions which rapidly occasion the appearance of 
the most évident trophic disorders in the muscles. 

Thus, after a traumatic lésion bearing on the course of a nerve, 
we sometimes see the power of motion remain, and only become en- 
feebled whcn trophic lésions hâve supervened in the muscle.^ It is 
important to note, besides, that muscular and cutaneous sensibility 
are often preserved, in a nearly normal condition, in cases of lésions 
of mixed nerves, even when rapid enfeeblement of the electrical 
contractility and consécutive muscular atrophy are carried very far. 
This is a fact to which due prominence has been given by MM. 
Duchenue (de Boulogne),"^ Mitchel, Morehouse, and Xeen.^ 

^ See tlie observation quoted by Duchenue (de Boulogne), loc. cit., p. 207. 

- "In paraly tic diseases consécutive on traumatic lésions of mixed nerves, 
the functional dérangements affect the sensibility of muscles less than their 
contractility. Thus a luxation of the shoulder-joiut having occasioned a lésion 
of the nerves that supply the arm, fore-arm, and hand, I liave knowii the 
patient to complain of rather marked muscular sensation, even when thes& 
muscles did not exhibit the slightest contraction under the influence of the 
most intense electrical excitation. Cutaneous sensibility is less affected than. 
muscular sensibility, in thèse same nervous lésions." — Duchenue (de Boulogue)^, 
loc. cit., p. 2t6. 

^' Mitchel, &c., loc. cit., p. 97. 



44 MODE OF ACTION. 

Is it probable tliat^ in sucb cases, tlie motor-fibres would hâve 
undergone great altérations, -wliilst tlie sensitive fibres, inter- 
mingled with tliem throughout tlie nerve, would hâve alone 
been spared ? But take an argument of a somewhat more 
direct bearing. After certain affections ôf the spinal cord, such as 
hsematomyelia, acute central myelitis, infantile paralysis, — diseases 
in whicli the initial lésion occupies most especially the grey matter, — 
it is common, when irritative nerve-lesions are in question, to see 
a diminution or a total abolition of the electrical contractility 
supervene in the muscles of the paralysed member. The muscular 
nerves hâve been several times examined, in such cases, under the 
microscope ; sometimes, they appeared normal, at others, they pre- 
sented to a certain degree the changes characterising fatty granular 
tlegeneration, but then thèse altérations were not at ail in proportion, 
either in extent or in intensity, to the muscular disorders. We 
shall hâve occasion again to refer to this important fact. 

You see by what précèdes that, in my opinion, the rapid aboli- 
tion of electrical excitability observed after nerve-section cannot 
be altogether assigned to the fatty granular degeneration of the 
meduUary sheath, and to the loss of excitability of the nerve-fibres, 
which would be the conséquence of this altération. If this be so, 
it becomes very probable that the phenomenon in question is, at 
least in part, the effect of some change supervening in the constitu- 
tion of the contractile substance, under the influence of the irritation 
transraitted to the primitive muscular fasciculus through the ter- 
minal nerve-branches. The rapidity which may mark the production 
•of this trophic trouble is not an argument against our hypothesis. 
Expérience, in fact, demonstrates that under the influence of certain 
causes, such, for example, as the abrupt interruption of the course 
of arterial blood, the muscular fibre may expérience still more 
rapidly — after a few hours merely — a modification which is un- 
doubtedly closely analogous, for it also reveals its existence by the 
abolition of the spécifie contractile power of the muscle.^ 

' " I divided oiic iscliiaiic iierve iii eacli of Iwo rabbits and two guinea- 
•pigs. Teu days after, 1 jicrceivcd that the divided iicrve prodiiccd no inove- 
iiieiit when I galvauised it. The muscles contractcd actively wheu J applicd 
both pôles to thein. Ilavingnoted this, I ticd the aorta bclow the origin of 
•Ihe icnal arterics, and three hours after 1 again tried the cllects of galvanism. 
Tiierc were no contractions set up in the Icg, neither wlieu 1 stiniulatcd the 
«erve, nor when 1 directly stinndated the muscles. I then loosed tlie ligature ; 



ALTERATION OF THE CONTEACTILE FIERE. 45 

To judge by the usual concaténation of phenomena, discerned 
by clinical observation^ tliis altération of the contractile fibre, 
manifested externally by modifications of the electrical contractility, 
would be the precursor and the first terra of a séries of graver 
lésions which gradually lead to the wasting of the muscle, and 
sometimes induce the complète and définitive abolition of its func- 
tions. Observations, to which we bave already referred and to 
which we shall hereafter return, appear to indicate that the lésions 
in question are largely of an irritative nature. One might be 
tempted after that, following the wanderings of the theory at 
présent in vogue, to consider thèse lésions as the more or les& 
direct conséquence of a paralysis of the vaso-motor nerves, conco- 
mitant with the paralysis of the motor muscular nerves. Amougst 
the arguments which hâve weight against this view, we may confine 
ourselves to pointing out one, namely, that the requisite signs of 
vaso-motor paralysis — the repletion of the blood-vessels and the 
augmentation of the température — are not to be seen, except on 
very exceptional occasions, in those patients who, after a nerve- 
lesion, suff'er from paralysis with rapid diminution of electrical 
contractility. 

Numerous facts attesta on the contrary, that the skin is generally 
pale and bloodless, whiist, at the same time, the local température 
is manifestly lowered from the very beginning.i 

II. 

Such, gentlemen, was the solution of the vexed question, which 
I had accepted, when I became acquainted with some new investi- 
gations that had been carried out in Germany. The results furnished 
by thèse researches, where numerous experiments on animais are 
paralleled with pathological facts, seemed to me, at first sight,. 
destined to destroy the whole édifice. For, indeed, to judge by the 
conclusions formulated by the authors, the opposition between 
passive and irritative lésions of the nerves, considered in référence 
to their effects on the contractility and the nutrition of muscles,. 

at the end of a very short time, tne muscles again became irritable. The 
ischiatic nerve did not recover its lost property. In this experiment the 
muscles of the leg, after having completely lost their irritability, only recovered 
it by nutrition, since neither the nerve-centres nor the divided ischiatic nerve 
could give it." — (Brown-Séquard, 'Journal de Physiologie,' t. ii, p. 77, 1859.) 
^ Duchenne (de Boulogne), loc. cit., p. 234. Mitchel, loc. cit., p. 13^ 
Polet, 'Etude sur la température des parties paralysées,' Paris, 1867, p. 7. 



46 • EXPERIMENTS ON ANIMALS. 

would be anytliing but establishecl. I shall set out by declaririg 
that the experiments to which I allude, instituted by Dr. Erb, in 
1868, and by MM. Ziemsseii and O. Weiss at the same period, but 
•independently, appear to liave been most carefully conducted. It 
remains to be seen wliether tliey liave the signification which has 
been attributed to them. 

Various nerve-lesions — by contusion, ligature, and section in a 
■very few cases — having been produced in rabbits, it was purposed 
^to make daily observations of whatever modifications of electrical 
> contractihty should take place, as regarded nerves and muscles, 
under the action of the continued current and of faradisation, each 
being employed in its turn. The electrisation. was applied some- 
times through the skin, as in cliuical cases, sometiraes directly, as 
in ])hysiological research. Dr. Erb also undertook the task of 
following as far as possible from day to day, the histological altera- 
■'tions corresponding to the changes of electrical excitability. 

Let us, in the first place, examine the phenomena observed in 
thèse cases in connection with the injured nerves. Suppose that 
the ischiatic nerve of a rabbit lias been injured from being crushed 
with a forceps. The lésion may be cither slight or severe. If it be 
«evercj an almost immédiate loss of the electrical contractility is 
■uoted, whether galvanism or faradisation be employed. On the 
régénération of the nerve, the recovery of the excitability takes 
place slowly as regards the central end, but quickl}^, on the contrary, 
in the distal. If the lésion be slight, the electrical excitability 
returns rapidly to the central end, whilst it never completely ceased 
io exist in the peripheral extremity. 

You see that thèse first results do not diverge perceptibly from 
those obtaiued ni former experiments, since it was likewise showu 
by them that a divided nerve loses its excitabihty from the first 
days. 

Let us uow study the phenomena which, in the new experiments, 
are set prominently forth by the electrical exploration of the muscles. 
Ilere, gentlemen, the results diverge in a marked manner from those 
furnished by former experiments, and approximate, on the contrary, 
very closely to pathological facts. 

Thus farailalc exploration indicates, from the first days, a dimi- 
nution, and afterwards — from live to fourteen days in intense cases, 
tolal abolition of the contractility. 

This is not ail. Galvanic exploration, also, detccts an cnfeeble. 



EXPERIMENTS ON ANIMALS. ' 47 

ment of the muscular contractions, froin the first days ; but^ after 
tlie second week, tliis enfeeblement is followed by an exaltation 
which persists during the wliole period of faradaic dépression, and 
which disappears in its turn, when faradisation résumes its power. 

The muscuLir lésions which correspond to thèse modifications of 
electrical contractihty hâve been studied with great care by Dr. 
Erb ; for many reasons they deserve the name of cirrhosis of the 
muscles, proposed by Dr. Mantegazza.^ They distinctly and com- 
pletely recall those lésions which the first-mentioned author pointed 
out in a case of facial paralysis, observed in mau. 

The first altérations make their apj)earauce in the interstitial 
connective tissue : from the first week, there is an accumulation of 
numerous rouuded cell-elements, recalling the tissue of granulation ; 
thèse afterwards assume an elongated form, disappear and give place 
to undulated connective tissue. The muscular fasciculi do not 
begin to show any altérations till about the second week. At this 
period, the diminution of their diameters is already noticeable. 
This atrophy makes rapid progress. However, the transversal stria- 
tion persists, and the fibres never offer any trace of the altérations 
characterisiug granular fatty degeneration. On the other hand, from 
a very early period, the nuclei of the sarcolemma are seen to mul- 
tiply and group together in little collections, whilst concurrently 
with this, the contractile matter présents différent phases of those 
modifications of structure, known as waxy degeneration. 

Such are the phenomena pointed out as consécutive on nerve- 
lesions which, according to our authors, would be équivalent to 
complète sections. Well, I hâve no hésitation in declaring that this 
parallel is far from being secure from criticism. The results obtained 
by Dr. Erb and by Dr. Ziemssen relate to conditions, undoubtedly, 
comparable with those which pathology gives us, but not at ail with 
those which were determined in the old experiments. Let us see 
liow thèse observers hâve proceeded in the great majority of in- 
stances. It will be found that they, almost always, ligatured the 
nerve more or less tightiy, or else crushed it more or less completely 
with a forceps. Now do not thèse circumstances furnish ample 
reasons for presuming that irritation of the nerve fikament may hâve 
intervened hère, as, in our opinion, it intervenes in pathological 
cases ? 

But there is no question of a mère presumption. The existence 
* Vide supra, note, pp. 36-37. 



48 CONTUSION AND LIGATURE OF NERVES. 

of an inflammation occupying, not only the neiglibourhood of the 
contused points^ but even the whole length of the peripheral portion 
of the injured nerve is placed beyond doubt by the descriptions of 
Dr. Erb himself. The neurilemma, especially, shows the charac- 
teristic signs of the inflammatory process ; from the first week, 
rounded cell-elements, having a solitary nucleus, are seen accumu- 
lated in great numbers. At a more advanced period, a more or less 
thick layer of fibrous tissue is found interposed between the nerve- 
filaments which hâve undergone the difl'erent phases of fatty degene- 
ration. As a conséquence the nerve-bundle has acquired a consist- 
ence which enables it to resist dilaceration, more tenaciously than a 
normal nerve. 

It seems to us rational to admit tliat, in thèse experiments as in 
the cases relating to man, the irritative lésions which occupy the 
nerves extend their influence to the muscles. It may^ indeed, appear 
diffîcult to conceive that a nerve, which has undergone the altéra- 
tions of fatty dcgeneration and is deprived of its motricity, should 
still possess a certain amount of vitality, and be capable, under the 
influence of an irritative lésion, of reacting on the muscular fibre and 
determining trophic disorders therein. It is proper, however, to 
point ont, in référence to tins, that the irritation probably dates from 
the very moment when the nerve was ligatured or contused. It is 
certain, besides, that the vitality is far from being definitely de- 
stroyed in nerves completely separated from the nervous centres, 
since the work of régénération can proceed without the distal and 
central ends being united.^ It is useful to remember, also, that it is 
only on hypothetical grounds and without proof positive that nerve- 
tubes, deprived of their meduUary matter and reduced to the axis- 
cylinder, are said to be denuded of every kind of vital property. 

We must not forget, however, that ligature and contusion are not 
the only means employed in the experiments of Drs. Erb andZiemssen. 
Thèse authors hâve also made sections and excisions of nerves, 
though in comparatively few cases. They state that the results are 
always identical, whether complète section or contusive lésion be in 
question. Eut if we go back to the détails of the observations, it is 
not difUcult to see that this conclusion cannot be accepted, without 
reserve. We find in Ziemssen's work, especially, a very significant 
chapter, considered from this point of view. It treats of cases in 
■which excisions of the ischiatic nerve were made, the excised por- 
' Vulpiau, 'Système nerveux,' loc. cil., p. 269. 



SECTION AND EXCISION OF NEEVES. 49 

tions being some millimètres in lengtli. Now, tlie results obtained 
in conséquence of sucli a lésion are very différent from those wliich 
this author and Dr. Erb remarked after ligature and contusion of 
nerves. They resemble, in many respects, tlie facts gleaned from 
physiological experiments. Thus, in the first place, the electrical 
contractility diminishes, after excision, in a progressive manner, but 
very slowly. It does not seem to be abolished until many months 
hâve passed, — not disappearing at an early period, varying from the 
tifth to the fourteenth day, as happens in the case of contused 
lésions. In the second place, we do not meet hère witli that opposi- 
tion between the eflPects of faradisation and those of galvanisation 
which vras observed in cases of contusion and which exists, as you 
remember, in most of the pathological cases where man is concerned. 
Thèse two modes of exploration, on the contrary, produce precisely 
parallel effects : faradaic contractility and galvanic contractility grow 
weak together, and together résume their wonted intensity, on the 
régénération of the nerve which, indeed, requires to be long waited for.^ 

If I do not deceive myself, we may conclude from this sketch that, 
when there is question of complète section or of excision of the nerves, 
the récent observations harmonise on ail essential points with the 
old researches. On the other hand, the results obtained by MM. 
Erb and Ziemssen, from the employment of contusion and ligature 
of the nerves of animais, are comparable with the phenomena which 
occur in man in conséquence of irritative lésions of mixed or purely 
motor nerves. 

Now, if this be so, the dissidences which we pointed out at the 

1 Compare the observation No. ii, fîg. 3, in the memoir of Ziemssen and 
"Weiss {loc. cit., p. 589), relative to a case of ligature of the anterior tibial 
nerve in a rabbit, with the observation No. ii (p. 593), conceruing excision of 
the ischiatic, in a rabbit also. In the first case, faradaic contractility seemed 
extinguished from the i2th day after the opération, whilst galvanic contractility, 
on the other hand, iucreased froin the 2nd day, and kept to a high level until 
the moment when faradaic contractility approached its normal standard again 
(the 44th day). In the second case, on the contrary, both faradaic and galvanic 
contractility became enfeebled together and progressively, but in a very slow 
manner. They ceased to be manifest almost simultaneously about the niiddle of 
the third month only, and made their appearance together about four months 
and a half after their cessation. MM. Ziemssen and O. Weiss express them- 
selves in the foUowing terms in référence to the effects of the excision of the 
ischiatic in a rabbit. "In animais, on which this opération had been per- 
formed," " galvanic excitability decliued progressively, and this enfeeblement 
was not preceded by a stage of exaltation. It proceeded slowly, at the same 

4 



50 LESIONS OF SPINAL COED. 

beginning of tliis study are smoothed away, and consequently we 
hâve reason to acknowledge, in speaking of rauscular affections^ tht 
fundamental distinction between the effects of tJœ absence of action, and 
tJiose ofmorbid action of the iiervous System which we hâve already put 
prominently forward in discussing cutaneous and articulai' affections.^ 

TrOPHIC DISORDERS CONSECUTIVE ON LESIONS OF THE 

Spinal Cord. 

Irritative lésions of the nervous centres, like those of the nerves, 
hâve the power of producing remote trophic disorders in différent 
parts of the body. In the expositipn of thèse consécutive altéra- 
tions which we are going to offer you, we shall again find the whole 
séries of morbid affections (witli the exception of some slight différ- 
ences) which we hâve remarked taking place after nerve-lesions. 
The knowledge of their history, which we hâve already gained, will 
singularly facilitate the task that remains to be accomplished. 

We may say, in a gênerai manner, gentlemen, that the skin, the 
mnscles, the joints, the bones, and the viscera, may become the 
seats of varions trophic disorders, conséquent on lésions of the 
spinal cord and of the brain. 

Let us take the affections of the muscles, in the first place, since 
the investigation we hâve just conciuded, has led us towards 
that question. The considérations we are about to set forth con- 
cerning thèse affections relate only to lésions of the spinal cord and 

rate as the enfeeblement of farado-muscular excitability. Galvaiiio excitabiiity 
disappeared iu the second half of the 3rd month, to re-appear towards the 7th 
or 8tli month" (Joe. cit., pp. 592 et 593). 

^ Récent experiments made by M. Vulpian (' Archives de Physiologie,' t. iv, 
1871-1872, pp. 757, 758), confirmiug on almost every point those of MM. 
Erb and Ziemssen, establish that the cfFects of section of peripheral nerves 
upon the physiological properties and structure of the muscles do not essen- 
tially differ from tliose caused by the application of varions irritative agencies, 
to the same nerves, such as local contusion, ligature, and cautery. On the 
othcr hand, the histological observations of MM. Neumann ('Archiv f. Heil- 
kunde,' Leipzig, 1868), Ranvier(' Comptes Rendus de l'Académie des Sciences,' 
3oth Dcccmber, 1872), Eichhorst (Virchow's 'Archiv,' 1874, i2th December), 
hâve placcd beyond doubt that in the peripheral extreniities of the divided 
ncrve altérations are constantly produced, e.ff., multiplication of the cells of 
the intcr-annular segment, which betray the présence of an irritative process. 
The opposition between the cffccts of nerve-section and of nerve-irritation 
caniiot, after this, bc any longer maintained in the strict terms in which it was 
set out in this lecture {Authors note to the 2nd Edition). 



CONSECUTIVE MYOPATHIES. 51 

medulla oblongata ; for it is at least very doubtful whether lésions 
of the brain proper hâve ever the effect of directly produciug altéra- 
tions of the muscular tissue, and this, as we shall see in due time 
and place, is a fact of the highest importance. 

Miisndar lésions consécutive on affections of the sjnnal cord. — Of 
irritative spinal lésions, there are sorae which détermine the very rapid' 
production of ail the kinds of functional and organic muscular altéra- 
tions which we hâve been studying, as conséquences of nerve-lesions, 
There are others, on the contrary, where the electrical contractility 
and the trophic condition of the muscles are preserved in perfect 
integrity, during a comparatively considérable lapse of time, for 
months and occasionally even for years. The muscle, in the latter 
case, only becomes slowly altered, under the influence of the func- 
tional inertia to which the limbs, stricken with motor paralysis, are 
subjected. Hence we find it possible to separate the irritative spinal 
disorders into two very distinct groups, which we shall pass suc- 
cessively in review. 

A. Inihejîrst group we place those of the irritative lésions of the 
cord which, as a rule, do not directly modify the nutrition of the 
muscles. They hâve one character in common : — ail tend to limit 
themselves to the white fasciculi of the cord, and if the grey matter 
be, at times, invaded, the région of the anterior cornua is respected, 
or at least the great multipolar nerve-cells which occupy that ré- 
gion are spared. Such are the différent forms of fasciculated 
scterosis, whether it be protopathic or consécutive on a circum- 
scribed lésion (en /b^er) of the brain or spinal cord, whether 
it occupy the posterior fasciculi only, or the latéral fasciculi only, 
or both simultaneously ; so long as the express condition stated 
be fulfilled, that is to say, so long as the integrity of the great 
nerve-cells be preserved, the lésions in question may attain their 
highest degree of development, may, for instance, invade the white 
fasciculi in their whole width and their whole height, without direct 
détérioration to the nutrition of the muscles animated by nerves 
issuing from the injured portions of the cord.i 

The scène would necessarily change, if the irritative process, ex- 
ceeding the limits usually assigned it, happened to extend from the. 
white fasciculi to the anterior cornua of the grey matter ; then, in. 

^ Cliarcot et JofFroy, "Deux cas d'atrophie musculaire progressive av^c 
lesiou de la substance grise et des faisceaux antéro-latéraux de la moel'ie 
épinière," in ' Archives de Physiologie,' t. il, p. 635. 



53 



CONSECUTIVE MYOPATHIES, 



conséquence of tlie participation of the motor-cells^ a more or less 
rapid and thorougli atropliy of the muscles might supervene. It 
is in this way, as I hâve pointed out elsewhere/ that the symptoms 
of gênerai spinal paralysis or of progressive amyotrophy are some- 
times superadded to the classic symptoms of posterior or latéral 
sclerosis^ &c. We hâve quite recently seen many cases of this kind 
where we had opportunities of observing necroscopically, in the most 
distinct manner, the altération of the nerve-cells to which^ according 
to my view, the trophic muscular lésion should be attributed." 

^ Cbarcot et Joffroy, loc. cit., p. 354. 

- See, amongst otlier cases, that receutly published by one of my students, 
M. Pierret,* ' Sur les altérations de la substance grise de la moelle epiuière 
dans l'ataxie locomotrice considérées dans leurs rapports avec l'atrophie muscu- 
laire qui complique quelquefois cette affection (in ' Archives de Physiologie,' 
&c., t. iii, p. 599). In this instance, phlegmasic action had extended from the 
posterior columns to the right anterior cornu of grey niatter, following the 
course of the internai radicular fibres of the correspoïKling side, the consécu- 
tive muscular atrophy was exactly liniited to the members of the riglit side 
{vide fig. i). 




* Fig. I. — This figure is illustrative of M. Pierrei's case (a summaryof wliich 
is appended) ; it represents a transverse section of the spinal cord taken 
from the lumbar eiilargement. Â. Posterior roots. B. Internai radicular 
fasciculi travcrsing the area of the posterior colunms. Tiie sclerosis is 
seen limited, in tlie posterior columns, to tlie course of thèse fasciculi. On 
the right, the phlegmasic process bas extended, along the course of the radi- 
cular fasciculi to the right anterior rornu, C. This cornu hasevidenlly saf- 
fered diminution, in every diameter, moreover tlie extcrnal group of motor 
cells bas complctely disappeared, and we (ind iu its place a dense, opaque, 
apparently fibroid tissue, containing numerous disseminated myeloc^tes. 



CONSECUTIVE MYOPATHIES. 53 

The same ruie holds goocl for dissemiiiated sclerosis {sclérose en 
plaques)} and for the diffused scléroses. The same may be said of 
primary partial myelitïc affections or of those determined by 
tumour-pressure, Pott's disease of the vertebrre, &c. Thèse diflerent 
diseases hâve no du'ect influence over the nutrition of the muscles so 
long as they do not involve the system of motor nerve-cells. 

AA^e can scarcely conceive of an exception^ save in those very 
rare cases, where the lésion, though circumscribed to the white 
fasciculi, occupies that portion of the cord traversed by bundles of 
nerve-tubes, from wliich issue the posterior roots. If thèse bundles 
sliould be at ail involved in the altérations, the équivalent of a 
lésion afCecting the peripheral nerves would necessarily be produced.^ 

Tlie following is a succinct account of a case whicli shows well the mechanism 
by which consécutive unilatéral fasciculated sclerosis may, by extending to the 
grey matter, détermine the production of muscular atrophy : 

A womau, aged about 70 years, had beeu stricken with left hemiplegia, con- 
sécutive ou the formation of a blood-clot in the right cérébral hémisphère. 
The members of the paralysed side, which had at au early period beeu con- 
tractured, commeuced to diminish in bulk, not quite two months after the attack. 
The muscular wasting affected ail parts of the paralysed members, in an 
uniforni manner ; it was accompanied by a very marked decrease of electrical 
contractility and made rapid progress. At the time when the atrophy became 
évident, the skin of the affected members, on ail points subjected to the slightest 
pressure, presented bullse which soon gave place to eschars. At the autopsy, 
we observed, on examiniug hardened sections of the braiu, that the descend- 
iug fasciculated sclerosis of the left latéral columu had beeu propagated to the 
auterior cornu of the grey matter of the correspouding side, and had there 
caused atrophy of a certain number of the motor-cells. 

' In the case of a woman, suÊFering from multilocular cerebro-spinal sclerosis, 
whoni we treated some years ago, oue ofthe sclerosed patches had invaded, uear 
the mid cervical région, almost the whole of the grey matter of the cord, for a 
certain height, and the auterior cornua in particular. At this level the nerve- 
cells mostly presented grave atrophie lésions, and a good number of them had 
vanished, without leaviug any trace. The woman's liands presented the 
déformation known as a griffe, i.e. they were claw-like. The muscles of 
the theuar and hypothenar régions, as well as the interossei were atrophied ; 
the fore-arms also showed great atrophy, limited to certain groups of 
muscles. 

^ In référence to partial myelitic affections, whether protopathic, or de- 
termined by the vicinity of a tumour, the following remark will not be out of 
place : — They are most commouly fouud at a pointof the dorsal région of the spinal 
cord, which they occupy for but a very small extent, iu height. It would foUow 
from this arrangement that if, whether primarily or iu conséquence of eonceutric 
extension of the morbid process, the auterior cornua of the grey matter 



54 CONSECUTIVE MYOPATHIES. 

B. The second group will include tliose affections of tlie spinal 
cordj the almost inévitable conséquence of which it is to détermine 
more or less grave disorders in the nutrition of the muscles. This 
group may be separated into two subdivisions : 

1°. The first includes those acute or subacute lésions, whether 
diffuse or circumscribed {en foyer), which involve a great length 
of both the white and the grey substances, but which generally 
predominate in the latter. They are commonly followed by great 
modifications of electrical contractility, and by a rapidly developed 
atrophy of muscular fibre. 

I will refer to acute central myelitis, in the first place. When 
it has been somewhat geueralised, and occupies, for instance, a 
considérable portion of the dorso-lumbar swelling, the early diminu- 
tion of electrical contractility in the lower extremities is a symptom 
which probably is never completely absent. Herr Mannkopf has 
seen, in such cases, the electrical contractility remarkably altered seven 
days after the appearance of the first symptoms.i When the 
patients are not too quickly carried off, you may follow the develop- 
ment of the correlated phenomena — the atrophy of the muscular 
masses soon shows itself, and the histological lésions of the primi- 
tive (ultimate) fasciculi become promptly perceptible. 

According to MM. Mannkopf- and Engelken^ thèse lésions are 
chiefly remarkable on account of the prolifération of the nuclei of the 
sarcolemma. They bear, in fact, the stamp of the irritative process. 
Hère also fatty degeneration of the primitive fasciculi is an ex- 
ceptional incident. As to the nerves which supply the affected 

became involved, the muscular lésions which resuit therefrom would be con- 
fined to very circumscribed régions of the thorax or even of the abdomen, and 
might not betray themselves during life, by any perceptible symptom. A,t ail 
times, the nutrition of the muscles of the extremities, if there be no compli- 
cation, remains perfectly intact, when the partial myelitis occupies the position 
we hâve just mentioned. It would be quite otherwise in any case where a 
focus of myelitis, cven though very mucli circumscribed, should occupy certain 
parts of the cervical or lumbar enlargemeuts. The muscular lésions super- 
vening, in conséquence of the invasion of the anterior coruua, would then 
hâve their seat in the extremities and would betray their présence by functional 
disorders, and by altérations of form, in those parts, which could not long 
«scape attention. 

' Mannkopf, ' Amtlicher Bericht liber die Versammlung Deutscher Natur- 
forscher und Aerzte zu Ilannover,' p. 251. Hannovcr, 1866. 

^ Mannkopf, loc. cil. 

^ Engelken, ' Beitrag zur Patholog. der acuten Myelitis.' Zurich, 1867. 



LESIONS OF MOTOR NERVE-CELLS. 55 

muscles, they were found by Herr Mannkopf, after repeated examina- 
tioiis, to be sometimes healtby, sometimes affected by comparatively 
slight altérations nowise • proportionate in intensity to tbe severity 
of the muscular lésions.^ 

Sjnnal apoplexij [hamatomyelio) should be mentioned in tbe 
second place. Tbis is an affection wbich, considered from tbe 
standpoints of patbogenyand patbological anatomy, differs essentially 
from common intra-cerebralbœmorrbage; for, in bsematomyelia, tbe 
effusion usually takes place in tbe midst of tissues wbicb bave 
already suffered modification from infiammatory action. Tbe blood 
is cbiefiy efFused in tbe grey matter, wbicb it often invades tbrougb- 
out tbe major part of its lengtb. Wben tbis bappens, diminution 
or even abolition of electrical contractility, supervening early in 
tbe muscles of tbe paralysed members, is a symptom wbicb seems 
constant. It was observed fourteen days after tbe development of 
tbe brst accident, by Levier ;~ on tbe very day of tbe attack, by 
CoHn (?) ; on tbe nintb day, in a case recorded by Duriau.^ Spinal 
apoplexy is an affection wbicb, in gênerai, is rapidly fatal ; it bas as 
yet furnisbed no opportunity of observing tbe bistological lésion of 
tbe primitive fasciculi and tbe atropby of tbe muscular masses, 
wbicb would doubtless uot fail to follow if life were prolonged. 

It is probable, gentlemen, tliat fractures and luxations of the 
vertébral column, by producing an irritation of tbe cord wbicb from 
partial tends to become gênerai, may bave tbe effect of determining, 
as Dr. Ducbenne (de Boulogne^) bas remarked, a prompt diminution 
of electrical contractility in tbe muscles of tbe paralysed member. 

2°. Tbe affections wbich compose tbe second category are 
tbe product of more délicate lésions. Tbese are, in fact, limited, in 
a seemingly systematic manner, to tbe grey matter of tbe anterior 
cornua, tbe eutire extent of wbicb tbey rarely invade ; we see tbem 
often very exactly localised in tbe circumscribed oval space occupied 
by a group or cluster of motor cells (fig. 3). 

Tbe neuroglia, in tbe affected parts, becomes usually opaque, 

' Vide supra, p. 36. 

- Levier, ' Beitrag zur Pathologie der E,uckenniarksapopIexie.' luaugural- 
dissertatiou. Bern, 1864. 

^ Duriau, ' Unioa Médicale,' t. i, 1859, p. 308. 

■* Duchenne (de Boulogne), Observation, p. 246, loc. cit., fracture of the 
vertébral column, about the niiddle of the dorsal région. The spinal cord 
softened for several inches, iu the dorso-lumbar région. Enfeeblement of the 
electrical contractility from the sixth day after the accident. 



56 



LESIONS OF MOTOE NEKVE-CELLS. 



denser, strewn with immerous myelocytes and consequently exhibits 
the signs of inflammatory action. At the same time, the nerve- 
cells présent différent degrees and différent modes of atrophie de- 



<l 





FiG. 2. — Fragment ofa transverse section ofthe spinal cord takenfrom the limhar 
région, in a case of infantile spinal paralysis occupying the right inferior 
extremiti/. The right anterior cornu of grey matter is represented. The 
lésions affect exclusively, the antero-exterual group of nerve-cells : a, cervi.v 
cornu posierioris ; b, postero-extenial group of nerve-cells ; c, autero-ex- 
ternal group. The cells of the latter group hâve completely disappeared, 
whereas those of groups b and d are perfectly distinct ; d, internai group ; 
c, the commissure. 

génération. But what are the éléments first affected ? Everything 
leads us to believe thèse to be the nerve-cells. It would, indeed, be 
difficult to comprehend how the altération could show itself strictly 
localised in the vicinity of the cells if its starting-point were in the 
neuroglia. There are cases besides, in which the atrophy of a 
certain number, or even of a whole group^ of nerve-cells is the only 
altération which can be discerned, on histological examination. The 
connective web préserves its transparency, in those points^ and ail 
the characters of normal structure, with but few exceptions. There 
are other not less significant cases, also, where lésions of the neuroglia 
appear much more developed about the central parts of a cluster 
of nerve-cells, than in the peripheral portion, and also much more 



INFANTILE SPINAL PAliALYSIS. 57 

manifest in the immédiate iieiglibourliood of the cells themselves, 
thau in the intervais between them, so that tliey appear like so 
many centres or foci, whence the inflammatory process radiated out- 
wards for some distance in every direction. On the other hand^ it 
caunot be admitted that the irritation was originally developed in 
the peripheral portion and ascended to the central parts along the 
anterior nerve-roots, for the latter generally présent, on a level with 
the altered points of the cord, only comparatively trifling lésions 
and not at ail of intensity proportiouate to the lésions of the grey 
matter. It appears évident, from ail that précèdes, that the motor 
nerve-cells are, in reality, the primary seat of the evil. Usually, it is 
true, the irritative process next invades the neuroglia, its second 
stage; and extends step by step to the différent régions of the 
anterior cornua ; but that is by no means necessary. Hence 
we must, a fortiori, regard as a consécutive and purely accessory 
fact, the extension, in certain cases, of the morbid process to the 
antero-Iateral fasciculi, in the immédiate neighbourhood of the 
anterior cornua of grey matter.i 

Infantile spinal paraljjsis is, up to the présent, the most perfect 
type of the affections which compose this category. The numerous 
researches made recently in France, in référence to the spinal lésions 
on which they dépend, concur to indicate, as an essential fact, the 
profound altération of a large number of motor-cells, in those 
régions of the cord whence the nerves emanate which supply the 
paralysed muscles.^ In the vicinity of the atrophied cells, the con- 
nective network almost always offers manifest traces of an inflam- 

' The views set fortli above relative to the rôle of the so-called motor nerve- 
cells iu the pathogeny of progressive muscular atrophy, iufautile paralysis, 
acute central myelitis, and of ail the amyotrophies arising from spinal causes, 
in gênerai, were stated in a lecture which I delivered at La Salpûtrière in June 
1868. Cf. Hayem, 'Archives de Physiologie/ 1869, p. 263. Charcot et 
Joffroy, id., p. 756. Duchenne (de Boulogne) and Joffroy, id., 1870. Thèse 
views hâve been utilised in the récent work of Dr. Hammond : ' A Treatise 
on Diseases of the Nervous System/ Sect. iv. 'Diseases of Nerve-cells/ p. 
683, New York, 1871. 

" On atrophy of the motor nerve-cells iu infantile paralysis, consult Prévost, 
in 'Comptes Rendus de la Société de Biologie/ 1866, p. 215. Charcot et 
Joffroy, " Cas de Paralysie Infantile Spinale, avec lésions des cornes antérieures 
de la substance grise de la moelle épinière/' in 'Archives de Physiologie,' p. 
135, 1870, pis. V et vi. Parrot et Joffroy, id., p. 309. Vulpian, id., p. 316. 
H. Roger et Damaschino, " Recherches Anatomiques sur la Paralysie Spinale 
de l'Enfance," in ' Gazette Médicale/ Nos. 41, 43, et suiv., 1870 (Gg. 2). 



58 PROGRESSIVE MUSCULAR ATROPHY. 

matory process. Judging from tlie gênerai aspect of tlie plieno- 
mena, we are induced to admit, as a higlily probable hypotliesis, 
tliat, in infantile spinal paraiysis, a superacute irritative action sud- 
denly seizes on a large nuuaber of nerve-cells and makes them 
promptly lose their motor functions. Some cells, wliicli hâve been 
but slightly attacked, will recover their functions some day, and this 
phase corresponds to the amélioration of symptoms which alvvays 
supervenes at a certain period of the disease. Others, however, 
hâve been more severely involved, and the irritation of which they 
were the seat is transmitted along the nerves to the paralysed muscles 
which, in conséquence, suffer trophic lésions of a more or less 
serious character.^ However it be, it is known that diminution 
or even loss of faradaic contractility may be observed, in certain 
muscles, barely five or six days after the abrupt invasion of the 
first symptoms. The emaciation of the muscular mass makes rapid 
progress, besides, and soon becomes évident. The altérations 
which, on histological examination, are found in the affected mus- 
cles are thèse : firstly, simple atrophy of the primitive fasciculi witli 
the transverse strise preserved ; and, secondly, the marks of a more 
or less active prolifération of sarcolemma-nuclei on some isolated 
fasciculi. The accumulation of fat, sometimes seen in old cases, 
seems to be a purely adventitious phenomenon." 

Progressive imiscular atrophy offers for our study the irritative 
atrophy of the motor cells in its chronic form.^ Hère we are not 
concerned with a superacute irritative process suddenly invading the 
nerve-ceDs, and laying hold on a large number of them. Thèse are 
now affected successively, one by one, in a progressive manner ; a 
considérable number of them are spared, even in the most seriously 

' Cbarcot et Joffroy, loc. cil. 

- Ibid., loc. cit. ; Vulpian, lor. cil. 

^ On atrophy of tlic motor-cells in progressive muscular atrophy, see Luys, 
' Société de Biolofçie,' iS6o. Durnénil (de Rouen), " Atrophie nmscuhiire grais- 
seuse progressive, histoire critique," Rouen, 1867. "Nouveaux faits relatifs à 
la pathogéaie de l'atropliie musculaire progressive," in ' Gazette hcbdom.,' 
Paris, 1867. Lockhart Clarkc, " On a Case of Muscular Atrophy," ' Britisli 
and Foreign Medico-Chirurgical Review,' July, 1872. "A Case of Muscular 
Atrophy," Beale's ' Archives,' t. iv, 1867. " On a case of Muscular Atrophy," in 
'Medico-Chir. Transactions,' t. iv, 1867. O. Schiippel, " Ueberllydroniyelus," 
in 'Archiv der Hcilkunde,' Leipzig, 1865, p. 289. Hayem, in 'Archives 
de Physiologie,' 1869, p. 263, pi. 7. Charcot et JolTroy, in 'Archives de J'iiysio- 
logie,' 1869, p. 355. 



GENERAL SPINAL PARALYSLS. 59 

compromised régions, uiitil nearly the lasfc period of the disease. The 
development of the muscular lésions corresponds to this mode of 
évolution of the spinal lésions. Thus, it is rare that the trophic 
disorders affect simultaneously ail the primitive fasciculi of a muscle ; 
hence it foUows that the latter may respond, in a more or less ira- 
perfect manner, to the command of the Will, and still enter into 
contraction under the influence of electrical excitations, even when 
its volume lias been very markedly diminished.^ 

There exist, indeed, at least two very distinct forms of progressive 
amyotrophy correlated to an irritative lésion of motor cells. One 
of them, whicli is 2^'>'^iopathic, arises exclusively from the lésion in 
question, and this form, priuiarily developed because of an original 
or acquired prédisposition, tends, as of necessity, to become gene- 
ralised. In the other form, to which we called your attention a 
moment ago, the nerve-cell is only secondarily affected, consecutively 
on a lésion of the white fasciculi, for instance, and as it were acci- 
dentally. Progressive amyotrophy, in the latter case, may perhaps be 
called symptomatïc, it has less tendency to become generalised, and 
its prognosis is certainly less gloomy.^ 

As regards adult spinal paralysis, and gênerai spinal paralysis 
(Duchenne de Boulogne) pathological anatomy has not yet given 
any definite décision. But to judge from the symptoms, it is at 
least very probable that thèse afl'ections also dépend on a lésion of 
the motor nerve-cells of the auterior cornua. Adult spinal paralysis 
resembles that of childhood by the almost sudden invasion of motor- 
paralysis, by the tendency which it shows to rétrograde, at a 
given moment, by the diminution or abolition of faradaic contrac- 
tility showing itself precociously in a certain number of paralysed 
muscles, and, finally, by the rapid atrophy which thèse same muscles 
•constantly exhibit to a more or less marked extent. A slovrer 
évolution, often occurring in a subacute or chronic manner, a ten- 
dency to become generalised, especially évident in the first stages, 
fréquent pauses, foUowed by invasion of hitherto untouched parts, 
distinguish, on the contrary, gênerai spinal paralysis, and make it 
resemble progressive muscular atrophy, with which it is sometimes, 

' Charcot, " Leçons faites à la Salpêirière in 1870." See also Hallopeau, 
in 'Archives de Médecine,' Septembre, 1871, pp. 277, 305. 

- On the two forms of progressive amyotrophy of spinal origin, see Charcot 
•et Joffroy in ' Archives de Physiologie,' 1869, pp. 756, 757. Duchenne (de 
Boulogne) et Joffroy in 'Archives de Physiologie,' 1870, p. 499. 



60 LESIONS OF THE BULBUS EACHIDTCUS. 

very erroneouslj, confounded in clinical practice. The former, 
however, is clearly separated from the latter by the following 
characters : the muscles of an entire extremity or of portion of a 
limb, are struck, en masse, in an almost uniform manner, with 
paralysis or atrophy; they présent, at a period but little remote 
from the commencement of the disease, very marked modifications 
of electrical contractihty ; usually, in conclusion, a period of 
recovery supervenes, during which the atrophied muscles regain, 
at least partially, their volume and their functions.^ 

Muscular lésions consécutive on affectmis ofthe hidbus racJddicus. 
This is a subject which has been, as yet, but little explored. How- 
ever some facts, which hâve accumulated until they now form a 
respectable number, gleaned from the history of labio-glosso- 
laryngeal paralysis and disseminated sclerosis [en plaques) tend to 
establish that, in the case of the bulbus as well as in that of the 
spinal cord, irritative lésions of the white fasciculi hâve no direct 
influence on the nutrition of muscles. Those, on the contrary, 
which affect the motor cell clusters distributed over the floor of the 
fourth ventricle, or the fasciculi of nerve-tubes emanating from thèse 
aggregations may, as I hâve demonstrated, détermine a more or less 
marked atrophy of the muscular fibres of the tongue, pharynx, 
larynx and orbicularis oris.''^ 

The summarised account which has been laid before you will suf- 
fice, I hope, to place in prominence the remarkable rôle which, ac- 
cording to the most récent researches, lésions of the anterior nerve- 
cells play in the production of trophic muscular disorders consécu- 
tive on altérations of the spinal cord. This rôle does not seem 
doubtful in the pathogeny of infantile paralysis and of the différent 
forms of amyotrophy of spinal origin. Its influence is, certainly, 
less distinctly demonstrated, though still highly probable, as regards 
hœmatomyelia, acute central myelitis, and, in a word, ail the irri- 
tative affections of the spinal cord in which the grey axis is found to 
be involvcd. On the other hand, the absence of ail participation on 
the part of the white fasciculi, and of the posterior cornua, in the 

' Duclicuue (de Boulogne), ' De l'eleetrisation localisée,' 3rd édition. 

- Compare Cliarcot,, " Note sur un cas de paralysie glosso-laryngée, suivi 
d'autopsie," in 'Archives de Physiologie,' 1869, pp. 356, 636, pi. xiii. Obs, 
de Catherine Aubel. Ducheimc (de Boulogne) et Jofl'roy, " De l'atrophie aïgue 
et chronique des cellules nerveuses de la moelle et, du bulbe rachidien," 
'Archives de Physiologie,' 1870, p. 499. 



INFLUENCE OP MOTOR NERVE-CELLS. 61 

clevelopment of the muscular affections in question is a fact wliicli 
lienceforth rests on abundant évidence. 

This acknowledged, gentlemen, we liave cause to inquire why 
lésion of the motor nerve-cells induces that of the muscular fibres, 
whilst even the gravest irritative altérations of the white fasciculi 
hâve no direct iniluence on the nutrition of the muscles. 

With respect to the first point, one cannot fail to imagine more 
or less plausible hypothèses which, however, are evideutly prématuré. 
The teachings of expérimental physiology cannot be called to our 
assistance hère ; its methods of ])rocedure, inferior to those of disease 
in that respect, are not sulïicieutly délicate to allow the nerve-cells to 
be attacked in an isolated manner. We must therefore, confine 
ourselves, at présent, to registering the facts as they are ofTered us 
in clinical practice, illustrated by pathological anatomy, and to point 
out that the motor nerve-cells, comparable in that respect to the 
peripheral nerves, possess the power, when they hâve become the 
seat of irritation, of modifying, by remote action, the vitality 
and structure of the muscles. 

As regards the second point, if what we hâve said concerning 
the effects of nerve-irritation be referred to, it may seem contra- 
dictory, at first sight, that the nutrition of the muscles should not be 
affected when the white fasciculi of the cord are occupied by inflam- 
mation. To show that the contradiction is only apparent it will 
suffice, however, to remind you that, in spite of the analogy of com- 
position, the white columns are not at ail comparable to the nerves. 
Experiments, in fact, reveal, in the latter, properties which are not to 
be found in the former, and vice versa. Anatomy also shows that 
the nerve-tubes which constitute the nerves are but to a very small 
extent the direct continuation of those which, by their union, form 
the white substance of the cord. Thèse fasciculi appear to be almost 
entirely composed of fibres which, arising either in the encephalon 
or in the cord itself establish, after the manner of commissures, 
communications between the spinal cord and the brain, or between 
différent points of the grey spinal axis. It was to be anticipated, 
from this, that, in many respects, the white fasciculi of the cord would, 
under the influence of irritative lésions, behave differently from the 
peripheral nerves. 

When I formed the idea of laying before you, gentlemen, the 
principal facts relating to the nutritive disorders which make their 
appearance consecutively on affections of the nervous System, I hoped 



63 IMPORTANCE OF THE SUBJECT. 

that my task might be brought fairly to an end, in the course oî 
two lectures. But, according as I advance in this exposition, the 
importance and extent of the question display themselves in ail 
their distinctness. Notwithstanding the détails which I hâve already 
given, I am far from having exhausted the subject, and I dare to 
hope that you will not hâve cause to regret the time that yet remains 
to be dedicated to its study. 



LECTURE III. 

DISORDERS or NUTRITION CONSECUTIVE ON LESIONS OF 
THE SPINAL CORD AND BRAIN. 

SuMMARY. — Cutaneous affections in sclerosis of tlie posteo'ior cohimns: 
papidar or lichenoid empilons, nrtlcaria, zona,piistular érup- 
tions ; thelr relations ivith tJie fulgurant pains ; the former 
appear to arise front the same organic cause as the latter. 

Eschars of rapld development {acute bed-sores) In diseuses 
qf the hrain and spinal cord. Mode of évolution of this 
skln-affectlon : eri/thema, bullce, mortlf cation of the derma, 
accidents consécutive on the formation of eschars : a, putrld 
infection, purulent infection, gangrenons emholl ; \), simple 
piorulent ascending meningitis, ichorous ascending meningltls. 
Acute bed-sore in apoplexy symptomatic qf circimscribed céré- 
bral lésions. It appears principally in the gluteal région qf 
paralysed extremltles ; its importance in prognosls. Acute bed- 
sore in dlseas es of the spinal cord; it generally occupies the 
sacral région. 

Arthropathles dependlng on a lésion qf the brain or spinal 
cord. A. Acute or subacute forms ; they appear in cases qf 
traumatic lésion of the spinal cord ; in myelltis occasloned by 
compression {tumours, Pott's dlsease), in prlmary myelltis, in 
récent hemiplegla, connected toith cérébral sqftening. Thèse 
arthropathles occupy the joints of paralysed limbs. B, 
Chronlc forms ; they seem to dépend, llke amyotrophles of sjolnal 
origin, on a lésion qf the anterlor cornua of the grey axis ; ob- 
served in posterior sclerosis {locomotor ataxla) and in certain 
cases qf progressive muscular atrophy. 

Gentlemen, — In treating of the nutritive disorders determined 
by lésions of the peripheral nerves, I gave you to expect that thèse 
consécutive affections would, for the most part, be represented in 



64 CUTANEOUS AFFECTIONS IN LOCOMÛTOR ATAXIA. 

cases of lésions of the spinal axis, It is true, we sliall not always 
find liere a servile imitation ; indeed, as a gênerai rule^ the trophic 
disorders of cérébral or spinal origin, as we shall often hâve occasion 
to note, bear v/ith them the distinctive stamp of their cause. But 
there are circumstances in which the reseinblance between affections 
of central origin and those which dépend on a lésion of the peri- 
pheral nerves is so striking that discrimination may be a most 
difficult task. We will cite, as examples of this class^ certain cuta- 
neous éruptions which sometimes supervene in the course of ataxia. 

I. 

The cutaneous affections, to which we hâve just alluded, may 
be classified as follows : a, papnlar or lichenoid éruptions ; h, nrti- 
caria ; c, zona ; d, pnstular éruptions, analogous to ecthyma. 

The following, in a few words, are the results of my observations 
on this subject. It is not rare to see the skin of the legs and thighs 
become temporarily covered with a more or less confluent papular 
or lichenoid éruption, conséquent on paroxysms of the fulgurant or 
shooting pains, characteristic of locomotor ataxy. In the case of a 
woman,at présent under treatmentatLaSalpêtrière,enormous patches 
of urticaria are produced, at every paroxysra, over the parts where the 
keenest pains are felt. In another case, the skin of the right gluteal 
région becomes covered with an herpetic éruption, limited however to 
the course of the nervous filaments which convey the pain. Tinally, 
a third patient presented, under analogous circumstances, still more 
remarkable phenomena. This woman, aged sixty-one years, was 
received into the hospital on account of blindness fsclerous atrophy 
of the optic nerves) about eight years ago ; she is now suffering 
from well-marked locomotor ataxia. In her case, the évolution of 
the disease has been very rapid, for the first paroxysms of shooting 
pains date from the month of ]\Iarch, 1865, and in July, 1866, the 
incoordination was so far advanced as to render walking difficult. 
Oae of thèse fits, which happened in Junc, 1 867, was of exceptional 
intensity. The pains which were really horrible, seemed fixed, during 
sevcral days,along the course of the cutaneous branches of the right 
lesser ischiatic nerve, and of that supplying the levator ani.i 

' The nerve called "relevcur de l'anus" by French anatomists, is a branch 
of tlie fonrth anterior sacral nerve, althouî^li the muscle, bearing the same uamc, 
rcccives twigs from the superficial pcrincal nerve (S.). 



THEIR RELATION TO FQLGURANT PAINS. 65 

During this time, the correspondiug parts of tlie skin became 
covered witli a great number of pustules, analogous to ecthyma, 
sorae of whidi proved the starting points of deep ulcérations. Besides 
this, a rouiided eschar of about two inches in diameter, wliich in- 
volved the derm iiearly throughout its whole thickness, developed 
in the riglit sacral région, a few inches from the médian liue im- 
înediately under the extremity of the coccyx. The sore persisting 
after the élimination of the sphacelated parts, cicatrisation was not 
complète until two months had elapsed. In another paroxysm, the 
flashing pains followed the direction of the vertical portion of the left 
internai saphenous nerve, and a pustular éruption was soon thrown 
out on the skin of the régions to which this nerve is distributed. 

There is one character common to ail thèse éruptions, and it is 
of a kind to show that we hâve not hère to deal with common dis- 
orders, — they ail make their appearance concurrently with certain 
intense and persistent exacerbations of the spécifie pains, which are 
in some sort pathognomonic of fasciculated sclerosis of the posterior 
columns, which it is customary to call fulgurant or flashing pains. 

Let me add, as another character, that the éruptions in question 
habitually show themselves along the course of the nerves invaded 
hy the fulgurating pain. 

Prom what précèdes you will observe that the existence of those 
cutaneous éruptions seems closely connected with that of the ful- 
gurant pains : hence it becomes at least very probable that one and 
the same organic cause présides over the development of both the 
former and the latter. 

What, then, is the reason of the présence of fulgurant pains 
among the symptoms of sclerosis of the posterior columns ? I do 
not désire to enter to-day upon a long discussion of this question 
which will meet us again ; it will suffice, at présent, to tell you that, 
in ail probability, thèse pains dépend upon the irritation set up, 
during their intra-spinai course, in those of the nerve-tubes emanat- 
ing from the posterior roots which, under the name of internai 
radicular fasciculi, {internai Jibroîis masses of tlie posterior roofs m 
the nomenclature of Kolliker),i pass, for a certain extent, through 
the area of the posterior columns before penetrating the posterior 
■cornua of the grey matter. 

It appears but little possible to connect the fulgurant pains with any 
■one of the following lésions : i°, atrophy of posterior roots, before 
' Kôlliker, ' Histologie Humaine/ P. i, pp. 345, 346. 

5 



66 PATHOGENY OF FULGURANT PAINS. 

entering the cord ; 2°, posterior spinal meningitis ; 3°, sclerosis of 
the posterior cornua of tlie grey matter ; 4°, irritative lésions of 
the spinal ganglia or of the peripheral nerves, — for thèse pains hâve 
been met with in a certain number of ataxic cases in which post- 
mortem examinations hâve demonstrated the absence of ail lésions 
of the kinds enumerated. 

In support of this proposition allow me, gentlemen, to recall the 
results of the autopsy which Dr. Bouchard and I made, in the case 
of a woman who died in this hospital, during the first period of 
progressive locomotor ataxia.^ This patient had experienced the 
spécial paroxysmal pains, in a high degree, lasting for some fifteen 
years, until the epoch of her death caused by an adventitious disease. 
No sign of motor incoordination had ever shown itself. The 
patient walked with ease, without throwing forward the leg, or 
stamping with the heel^ nor did closing the eyes affect her certainty 
of movement. On post-mortem examination, we saw that the pos- 
terior roots had preserved their normal characters, and beyond some 
equivocal traces of meningitis, the only perceptible lésions met with 
occupied the posterior columns and consisted of a multiplication of 
neuroglia-nuclei with thickening of the meshes of the reticulum, but 
without concomitant altération of the nerve-tubes. To complète 
the démonstration, I could cite many cases of the same kind where 
the fulgurant pains had been likewise very intense, and where, on a 
post-mortem examination, I was unable to discover the existence of 
any altération whatever, either in the posterior grey cornua, or in 
the peripheral nerves, or in the spinal méninges. 

ïrom this it would appear necessary that we should seek, in the 
irritative altération of the posterior columns of the spinal cord, the 
starting point of the fulgurant pains of ataxic patients. But it 
seems scarcely probable that ail parts of thèse fasciculi ought to be 
indiscriminately arraigned on this count; everything, on the contrary, 
induces us to believe that the sensitive fibres, issuing from the pos- 
terior roots, which compose a portion of theinternal radïcular fasciculi 
should alone be incriminated. Thèse fibres would participate, from 
time to time, pcriodically^, in the irritation whose permanent seat is 
in the coluinns tlicmselves ; and thus would be produced those 
paroxysms of shooting or flashing pains which, in accordance with 

' " Douleurs fulgurantes de l'ataxic, saus incoordination des mouvements, 
sclérose commençante des cordons postérieurs de la moelle ("pinièrc," iu 
* Comtes llcndus des Séances et Mémoires de la Société de Biologie," 1866. 



lERTTATION OP RADIOULAR FASCICULI. 67 

a well-known physiological law are referred to tlie periphery, 
altliough in reality due to a central cause. 

How are we to understand the appearance of tlie cutaneous 
éruptions sometimes observed in ataxic patients, at the very time of 
tlie occurrence of fulgurant paroxysms of abnormal intensity ? It 
is certain that the nerve fibres which form the internai radicular 
fasciculi are not ail sensitive ; tliere are, for instance, at least some 
amongst them which assist in the accomplishment of reflex actions ; 
there are others also, no doubt, at least it is what thèse cutaneous 
éruptions tend to demonstrate, which belong to the system of centri- 
fugal nerves and which possess a more or less direct influence over the 
exercise of the nutritive functions of the skin. The irritation of the 
latter class of fibres, an irritation more difficult to set up than that 
of the sensitive fibres, should be invoked to explain, in the cases I 
hâve above alluded to, the production of papular affections at one 
time, and, at another, of vesicular, pustular, or gangrenons disorder. 

Are the posterior fasciculi the only departments of the spinal 
cord, the irritation of which is capable of determining such aff'ec- 
tions ? This is a question which must remain unanswered for the 
présent. Ail that can be said is that such éruptions hâve not yet 
been observed, except where there was some complication, in cases 
of irritative lésions confined to the antero-lateral columns, or to the 
anterior cornua of the grey matter ; and as to the part which the 
posterior cornua may play, in this respect, we are in the most 
complète ignorance upon that subject. 

On the other liand, some facts hâve been collected which tend to 
establish that zonais sometimes developed underthe direct influence 
of partial lésions of the encephalon. Thus, in the case of an aged 
woman attacked with hemiplegia, whose history has been recorded by 
Dr. Duncan, an éruption of zona appeared on the thigh of the para- 
lysedside; motor paralysis had supervened almost simultaueously 
with the éruption, and both passed away nearly at the same tiine.i 

In the case of a child, recorded by Dr. Payne, the zona, which 
marked out the course of superficial branches of the anterior crural 
nerve, showed itself three days after the develo]nnent of a hemi- 
plegia occupying the same side of the body as the éruption." 
Thèse cases, which can be multiplied, are undoubtedly very inter- 
esting; unfortunately, they hâve been related in a very summary 

' 'Journal of Cutaneous Medicine,' &c., 69. Erasmus Wilson, October, i86â. 
- ' British Médical Journal,' August, 1871. 



68 KELATION OF ZONA TO ENCEPHALIC LESIONS. 

mauner onl}', and caution is needed, I tliink, in drawing conclusions 
from them, which may prove prématuré. I can^ in fact, cite a case 
in many respects analogous to the preceding, whicli I recently 
observed at La Salpêtrière, and where the cause of the zona was 
most probably the irritation of a peripheral nerve. Hère again, 
the seat of the vesicular éruption was in the inferior extremity of 
the paralysed side, where it followed the distribution of the super- 
•iicial twigs of the cutaneous perineal nerve. It showed itself also, 
simultaneously with the hemiplegia which, making an abrupt 
appearance, was correlated to the formation in one of the cérébral 
hémisphères of a focus of ramoUissemeut, itself being determined by 
the emb&lic oblitération of a posterior cérébral artery. As to the 
zona, it was produced, I believe, after the following mechanism ; a 
spinal arterial brandi,^ arising, no doubt, from one of the latéral 
sacral arteries was, on a post-mortem examination, found to be ob- 
structed by a blood-clot, and to form a comparatively voluminous 
■cord, adhering to one of the posterior spinal roots of the cauda 
equina. It is probable that, on its passage througli the sacral 
foramen, this arteriole, exceedingly distended by the thrombus had 
compressed either the spinal ganglion, or an initial brauch of the 
ischiatic nerve, so as to set up irritation in it. A vegetating ulcéra- 
tion, which was noticed on one of the sigmoid valves of the aorta 
appears to hâve been the starting point of ail the accidents which 
•we hâve just described." 

You will observe that, in this case, the coexistence of the hemi- 
iplegia and of the vesicular éruption resulted to a certain extent from 
a fortuitous coïncidence. Ilowever it be, in default of zona, there 
are other trophic disorders of the skin, the existence of which 

'. Oiie of the rami mechdlœ spinalis, see N. Rudiuger, " Arterienverzweigung', 
iii dem Wirbelcanal, &c.," in ' Verbreituug des Sympatliicus,' p. 2, Mûnclien, 
1863. 

^ The following are the principal détails of this case which présents a fine 
example of ulcérons endocarditis, with multiple emboli and atyphoid condition. 

The patient Lacq, .... aged 22 years, a soldier, M-as admitted on the 28lh 
Dcccmbcr, 1870, to the Salpêtrière ambulance (fever ward). He had been 
sufl'eriug, it seems, from an intense fevcr for two or tliree days. On the day 
of admission the following symptonis wcre noted : severc cephalalgia, pains in 
the loins, diarrhœa. The patient cannot swallow the smallcst quantity of 
liquid without bcing taken witii nausca and voniitiiig. Skin hot, puise very 
fréquent. It was rcgarded as a case of typhoid fevcr. Noisy dclirium during 
the nigiit. Next day, 29th December, was noticed the existence of an almost 
complète hemiplegia of the Icft side. The paralysed mcmbers were not rigid ; 



" DECUBITDS ACDTUS : ACUTE BED-SOEE. 69? 

may sometimes be attributecl to tlie influence of an encepbalic lésion. 
This is a fact wbich, I hope at least, will soon be placed beyond 
doubt. 

IL 
Eschars of rajiiil development. Decuhiius acutus : acute led-sore} — 

incomplète facial paralysis, on tlie left side, likewise existed. The eyes are 
constantly directed to thje right side, and there is nystagmus. Puise 120; 
rectal température 40*5° Cent. On tlie breast, fore-arms, and thighs, the skin- 
shows a great number of little ecchymoses, somewhat resembling flea-bites, — - 
fréquent respirations, sibilant râles. — Tyœpanitis. On the antero-external 
surface of the left paralysed leg, there exists an éruption of zona which 
answers exactly to the distribution of the superScial twigs of the cutaneous 
perineal branch of the musculo-cutaneous nerve. The first group of vesicles is 
seen above and below the patella; a larger group is disposed in a vertical:' 
straight line which descends to the middle third of the leg ; the third group 
occupies the neck of the foot before and inside of the external malleolus. The 
éruption is tolerably developed. It is remarked tliat some traces of it existed 
the day before, — that is to say, previous to the hemiplegia. On the 3oth, the 
éruption is in fuU vigour. The patient succumbs at 4 o'clock in the afternoon. 

Âutopsi/. — One of the sigmoid valves of the aorta is ulcerated and covered 
with végétations, fibrinous, soft and reddish in appearance. The niesenteric 
glands are somewhat red and swolleu, but there exists no trace of dothien- 
enterical éruptions or ulcérations in the sniall or large intestines. Numerous 
ecchymoses are observed ou the viscéral and pariétal pleurce, in the pericardium, 
and in the peritoneum. The spleen and kidneys présent infarcti in différent 
stages of development. ïlight cérébral hémisphère; on many points of the 
occipital lobe the pia mater, which is much iujected, présents large patches of 
sanguine suffusion. The lobe itself is softened throughout nearly its whole 
extent ; the cérébral niatter there assumes a greyish colour, and at one point 
in the midst of the softened parts we note an effusion of blood, as big as an 
almond. The posterior cérébral artery of the same side is completely obliterated 
by a thrombus. The spinal cord, prepared with chromic acid, and examined in 
thin sections, présents no perceptible altérations. At the cauda equina, on the 
left side, we found adheriug to one of the posterior spinal roots which give 
origin to the sacral ])lexus, an arteriole (spinal branch, arising froni the latéral 
sacral artery) distended by ablood-clot. The obliterated artery, equal in size to a 
crow-quill, may be followed from the point where the root has been eut not far 
from the corresponding sacral foramen, to the spinal cord ; upon this it can 
still further be followed the whole length of the lumbar enlargement, where ife 
ascends along the posterior médian fissure, contrary to the usual arrangement 
of the posterior spinal arterial plexus. 

' Lecubiiîis (when qualified by the adjectives acutus, clironicus, ominosîts) 
signiûes, not the position of the patient in bed, but the bed-sores supposed 
to resuit from such position. This term, though etymologically objectionable, 
is generally employed in foreign hospitals. As its adoption in this translation 
might confuse, and appears to be unnecessary, the term " bed-sore " has beeu 
substituted (S.). 



70 MODE OF EVOLUTION. 

I hasten to leave tlie question of éruptions occurring in locomotor 
ataxia, which, on the whole, hâve but a secondary importance, in order 
to draw your attention, in a very spécial manner, to another affection 
of the skin which holds a most important position in the cHnical 
history of a considérable number of the diseases of the brain and 
spinal cord. 

The cutaneous affection, which I am about to discuss, shows 
itself at first under the form of an erythematous patch, on which 
vesiculae and buUge are rapidly developed ; it terminâtes very often 
in mortification of the skin and subjacent tissues. 

Usually it occupies the sacro-gluteal régions; but it may also 
appear almost indifferently on ail parts of the trunk or members 
subjected, in the decubitus, to a somewhat continuous pressure. 
Even a very slight and very short pressure sufhces to make it 
appear in certain cases. Finally, there are other cases still, though 
thèse indeed are very exception al, in which it seems to be pro- 
duced without the intervention of the least pressure or of any 
other occasional cause of the same kind.^ 

This is a very différent affection from ail those varions éruptions 
which are so commonly remarked over the sacrum in patients con- 
demned by différent disorders to long maintain a recumbent position 
in bed. Thèse éruptions which are sometimes erythematous and 
lichenoid, sometimes pustular and ulcerous, sometimes papular, 
having a deceptive resemblance to syphilitic sores (^placfies mu- 
queuses), are generally occasioned by repeated and prolonged contact 
with irritating substances, such as urine or fsecal matters. They, 
as well as acute bed-sore, may become the starting points of genuine 
eschars ; but the acute bed-sore is distinguished from the former 
by important characters, namely : firstly, by appearing shortly after 
the commencement of the primary disease, or following on a sudden 
exacerbation ; and, secondly, by a very rapid évolution. 

On account of the peculiar interest belonging to it, the affection, 
in question, certainly deserves to be designated by an appellation pro- 
per to itself. One of the few authors who hâve made it a spécial study, 
Herr Samuel, lias proposed to characterise it by the name oidecnbitus 
ac2itus or eschar of rapid formation. He desires thus to distinguish it 
from (lecubilus chronicus, that is, from the dermal necrosis which 

^ Brown-Séquard, ' Lectures on the Central Nervous System,' Philadclphia, 
1868, p. 248. Couyba, 'Des Troubles Tropluques,' &c., Thèse de Paris, 1871 
P-43- 



CHAEACTERISTICS OP ACUTE EED-SOEE. 71 

appears long after tlie invasion of tlie disease whicli occasions its 
existence. We propose to accept this appellation, wliilst reminding 
you, however, tliat the raortitication of tlie skin is not everythiug 
in clecnbitus acutiis} It answers, on the wliole, to the most ad- 
vaneed phases of the morbid process. It may happen, indeed, that 
the vesiculse or bullse will dry up and disappear without that portion 
of the derm, on -which they were seated, presenting the least trace of 
necrosis. This is principally observed when they are produced on 
parts where the pressure has only been of short duratiou, of little 
intensity, and, so to speak, accidentai, as over the ankles, on the 
inner surface of the knees, the legs, or the thighs. Now, it behoves 
you to be able to recognise the significance of thèse vesiculse and 
bullse, from their first appearance on the scène ; for, even at that 
period, they enable us under certain circumstances to formulate a 
prognosis, with certainty. 

The opportunity has been given me, many times, of following as 
it were day by day, hour by hour, the évolution of the acute bed- 
sore, in cases of apoplexy consécutive on hsemorrhage, or on soften- 
ing of the brain which we so often meet with in this hospital.^ 

I can refer to the observations I made in regard to this, in the 
gênerai description which follows, for I hâve been able to establish, 
from another stand-point, that the acute bed-sore connected with 
brain- diseases does not essentially differ from that which arises under 
the influence of spinal lésions. 

Some days or even some hours only after the manifestation of the 
cérébral or spinal affection, or again, following on a sudden exacer- 
bation of thèse affections, there appear on certain points of the skin 
one or many erythematous patches, variable in extent and irregular 
in shape.^ The skin there has a rosy hue, sometimes it is dark red, 
and even violet, but the colour disappears momentarily on pressure 
with the finger. Under somewhat rare conditions, which hitherto I 
hâve met with almost entirely in cases of spinal lésions, there ap- 
pears besides, iuvolving the derm and subjacent tissues, an <?/?/;«- 
7'enili/ phlegmonous tiimef action, which may be accompanied some- 

' See note ^ p. 69. 

- Cliai-cot, " Note sur la formation rapide d'une escliare à la fesse du côte 
paralysé dans l'hémiplégie récente de cause cérébrale," ' Archives de Physiol. 
normale et pathol./ t. i, 1868, p. 308. 

^ I hâve ascertained, anatomically, that in such cases the derm is infiltrated 
^vith leucocytes, as happens in erysipelas. 



72 CHAKACTEEISTICS OF ACUTE BED-SOEE. 

times by acute pain, if the région bas not been previously smitten 
with aiiœsthesia. 

On the morrowj or after-morrow, vesiculœ or bullae make their 
appearance tovvards the central part of the erytliematous patch ; 
they contain a liquid, sometimes colourless and perfectly transparent, 
sometimes more or less opaque, reddish, or brown-coloured. 

Matters may remain so, as we bave already mentioned, and then 
the vesicles and blebs soon wither, dry up^ and disappear. At 
other times, however, the elevated epidermis becomes torn, drops off 
in pièces, and lays bare a bright red surface strewn with bluish and 
violet points or patches, corresponding with a sanguine infiltration 
of the derm. In such cases the subcutaneous connective tissue, and 
sometimes even the subjacent muscles are themselves already invaded 
by sanguine infiltration. This fact I bave repeatedly verified by 
post-mortem examination. 

The violet patches extend rapidly in width and their edges soon 
run together and unité. A short time after, there supervenes in the 
affected part, a mortification of the derm which, at first superficial, 
soon grows profound. Prom that time, the eschar is constituted. 
Later on cornes the development of the work of reaction and élimi- 
nation, followed, in favourable cases, by a period of réparation which 
is too often impeded in its course. It is unnecessary for me, I 
think, to expatiate on this point. 

I bave been occupying your attention with minute détails, but I 
trust I shall induce you to acknowledge that they bave their own 
peculiar interest. E. Bright thought tbem sufïiciently worthy of 
notice and novel enough to believe he should insist upon them in 
bis *' Reports of Médical Cases/' and should get wax models made 
of the bullse of acnte bed-sore, observed in a case of traumatic 
paraplegia.i Thèse models still figure, no doubt, in the muséum of 
Guy's Hospital. 

' It will not be deemed iiiappropriate to quote hère the remaiks which R. 
Bright lias appended to his rases of affections of the spinal cord, with rapid^ 
formation of bulhc and eschars, wliicli he has consigued to Jiis " Reports of 
Médical Cases," (t. ii, ' Diseases of the Brain and Nervoiis System,' London, 
1831). First cornes a case wherc softcning of the spinal cord supervened, 
without any known external cause, in a young woman aged 21 ; the lésion 
occupied the lumbar enlargement immediately above the cauda equiua. Tha 
case sugj^ested the following reflectious : 

" Anotiier curious circumstar.ee connectcd with paralysis of the lower 
cxtrcmilics is illustratcd by this case : — the tcndeucy which is observed iu suoli» 



CONSECUTIVE AFFECTIONS. 73 

Since then, as far as I know, this subject lias but sh'ghtly ar- 
rested the attention of observers, with a few rare exceptions.^ Ifc 
would be unjust^ however, not to acknowledge that, in cases of typhus 
and typhoid fevers, a cutaneous affection, which offers the closest 
analogies with this disorder and which, perhaps, partly dépends on 
analogous conditions, has been minutely described in Trance by 
Piorry,'- and in Germany, by Pfeiifer.^ 

Let us return, gentlemen, to the hed-&ore provoked by diseases 
of the nervous centres. You know too well the accidents which 
eschars, from whatever cause arising, are capable of engendering foi? 
me to indulge in a detailed description. Allow me, however, to 
sketch out in a few words the principal amongst them, for you must 
expectto see them often figuring in the lastperiod of a greatnumbei? 
of affections of the brain, and especially of the spinal cord. 

The eschars, if they but attain a certain extent, constitute, as you 
are aware, dangerous foci of infection ; and, in fact, putrid intoxica- 

affections to the formation of vesications or bullœ, wLicli frequently make 
their appearance in a iiiglit, on some part, as the knee, the aukle, or the 
instep, where accidentai pressure or irritation has taken place ; they contain a 
limpid fluid which after a few days becomes opaque. It has sometimes struck 
me that this connexion between interrupted nervous action and the formatioa 
of bullas, might hereafter be found to throw light on that most singular 
disease herpès zoster which, from the peculiar pain with which it is accom- 
panied, as well as from its strict confinement to one side of the body, seems to 
be couuected with some peculiar condition, perhaps the distension of the 
sentient nerves." (p. 383.) 

Three other cases relating to traumatic lésions of the spinal cord (caused by 
a fall from a height, the passage of a wagon, &c.) are comniented on as foUows l 

" The two most remarkable points to be incidentally uoticed in the fore- 
going cases are, first, the diseased state of the bladder, resulting from its 
diminished power to resist iujury, and from the changes takiug place in the 
condition of the urine, detained in its most depending part, which becomes- 
one of the most fréquent causes of fatal irritation in paraplegia ; — and secondly,. 
we observe the occurrence of bullœ on the paralysed limbs, to which circum- 
stance 1 hâve aheady alluded in sofne reniarks made at p. 383 ; the geueraL 
inability to resist iujury is likewise marked by extensive sloughing of ail the 
paralysed parts on which pressure is made." (p. 423.) 

' After R. Bright, we must specially refer to Sir Benjamin Brodie ("Injuries 
of the Spinal Cord," ' Med.-Chir. Transactions,' t. xx, 1837,) and Brown- 
Séquard {loc cit.). 

" A. Touzé, " Des dermopathies et des dermonécroses sacro-coccygiennes,'* 
Thèses de Paris, 1853. 

^ Kerchensteiner's "Bericht," in 'Henle und Pfeiifer's Zeitschrift fiir ra- 
lionelle Medicin,' Bd. v. See also Wunderlich, 'Pathologie,' t. ii, p. 285. 



74 CONSECUTIVE AFFECTIONS. 

tion, denoted by a more or less intense rémittent fever, is one of tlie 
complications they most commonly provoke. 

Next cornes purnlent infection, with production of metastatic 
abscesses in the viscera.^ This species appears to be seldom met with. 

We sball also notice gangrenons emholi. In tliis variety, tlirombi 
impregnated with gangrenons ichor are transported to a distance and 
give rise to gangrenons métastases, which are principally observed 
in the lungs. This is a point upon which Dr. Bail and myself hâve 
insisted in a work published in 1857.- But long before us, and 
even long before the theory of embolism had been Germanised, 
M. Foville had expressed his opinion that a considérable number of 
cases of pulmonary gangrené, observed in the insane, and in différent 
diseases of the nervous centres, are caused by "the transport into the 
lungs of a part of the fluid which bathes the eschars of the breech.''^ 

The process of mortification tends gradually to invade the 
deeper tissues. The ruin that results is sometimes carried to the 
highest degree; thus the trochanteric serous bursse may be laid 
open, the trochanter dennded of its periosteum, the muscles, the 
nerve-trunks, and arterial branches of a certain calibre laid bare. 
But the most dangerous accidents are those determined by the 
denudation and loss of substance of the sacrum and coccyx, the de- 
struction of the sacro-coccygean ligament, and the consécutive open- 
ing of the sacral canal or arachnoid cavity. In conséquence of 
thèse disorders, the pus and the gangrenons ichor may proceed to 
infiltrate the fatty cellular tissue which envelops the dura mater, 
or even, if this membrane be destroyed in any point, it may pene- 
trate into the cavity of the arachnoid.^ 

Under such circumstances, grave cerebro-spinal complications 

' Billroth und Wàckerling, in ' Langenbeek's Archiv fur Klin. Chir.,' Bd. i, 
1861, § 470. Fracture of the sixtli dorsal vertebra, rapid formation of cschar 
on sacrum. Manifest symptoms of pyœmia : six or eight abscesses on the 
surface of the kidneys. Midderdorf, ' Knochenbrilcb,' § 62. Fracture of 
the eightb dorsal vertebra. Rapid formation of eschar ; pyœmia ; metastatic 
abscesses in tlie lungs. 

- " De la coïncidence des gangrènes viscérales et des affections gangreneuses 
extérieures, in 'Union Médicale/ 26 et 28 Janvier, 1860. 

^ ' Dictionnaire de Méd. et de Chir. Prat.,' t. i, p. 5,'^6. 

'' B. Brodic, loc. ciL, p. 153. Velpeau, 'Anatom. Chirurgicale.' Ollivier 
(d'Angers) 'Traité des maladies de la moelle épinière,' t. i, pp. 314, 324, 3rd 
édition, 1837. Moynier, "De l'eschare du sacrum et des accidents qui peu- 
vent en résulter " (' Moniteur des Sciences Médicales et Pharmaceutiques,' Paris, 
1859). Lisfranc, 'Archives Générales de Médecine,' 4c année, t. xiv, p. 291. 



PATHOGENT OF ACUTE BED-SOEE. 75 

supervene; they may be collected into two principal classes. At 
one time we see a simple purulent ascending meningitls ; at anotlier, 
a sort of ichorous ascending meningitis, of which Lisfranc and 
Baillarger hâve reported many remarkable examples. In such a 
case, it is found that a puriform, greyish, acrid, and fœtid liquid 
steeps the méninges and the cord itself, sometimes the lower part 
only is bathed in it, sometimes tlie wliole cord. This liquid is oc- 
casionally found at tlie base of tlie encephalon, in tlie fourth 
ventricle, in the aqueduct of Sylvius, and even in the latéral ven- 
tricles. In ail thèse points the cérébral matter is discoloured at 
its surface and to a certain depth, taking a slaty bluish tint which 
has several times been considered, but very wrongly, as constituting 
one of the characters of gangrené of the brain.i M. Baillarger 
was the fîrst, I believe, to recognise the real nature of this altéra- 
tion. Wliat we hâve to note there is, above ail, a phenomenon of 
imbibitiou, macération, and dyeing. Remark that always, when 
ichorous cérébral meningitis has a sacral eschar as its starting point, 
the slaty tint is found throughout the whole extent of the spinal 
cord, it is constantly better marked there than in the encephalon, 
and more manifest the nearer you keep to the eschar. On the con- 
trary, in the case where a sanious ulcer of the face, a cancroid for 
instance, after having destroyed the bone, has denuded the dura 
mater, the slaty coloration induced by ichorous macération may, as 
I hâve many times observed, remain limited to the anterior lobes of 
the brain, in the régions corresponding to the bottom of the ulcer. 

To thèse complications which I hâve been only able to indicate in 
a very summary manner, we must with Ollivier (d'Angers) connect 
the grave cérébral or cerebro-spinal symptoms, as yet but ill-defined, 
which rapidly terminate life in a great number of cases of disease 
of the spinal cord. 

We hâve now to enter upon détails and to show you the prin- 
cipal circumstance s under which acute bed-sore is produced, under 
the influence of lésions of the brain and of the spinal cord, as well 
as the varieties of position and of évolution which it présents, 
according to the variety or seat of the lésion which has provoked its 
appearance. We shall also hâve to inquire whether the mode of 
production of this trophic lésion of the skin comes under the 
gênerai theory which we hâve hitherto had to accept. With this 

' Dubois (d'Amiens), ' Mémoires de l'Académie de Médecine,' t. xxvii, p. 50, 
1865, 1866. 



76 BED-SORE IN CEREBE.\L LESIONS. 

aim, we shall successively review tlie différent affections of the brain, 
and of the cord which may give rise to acute bed-sore. 

A. Of acuie bed-sore m apoplea:// symptomaiïc qf cerelral lésions- 
in focal centres. It is especially observed in the apoplexy consécu- 
tive on intra-encephalic hœmorrhage, or on partial softening of the 
brain. But it may also be produced in meningeal hœmorrhage, in 
pachymeningitisj and finally in cases when intra-cranial tumours 
give rise to apoplectiform attacks. Thç latter bave often given me 
opportunities for observing it in patients attacked with partial ence- 
phalitis caused by wounds received in battle.^ 

' The courtesy of my coUeague, JNI. Cruveilhier, surgeon to La Salpêtrière,, 
euables me to record the foUowing fact, which I give as an example of the 
last-meutioned class. 

Tlie patient, Louis Ernst, a Saxon soldier, was picked up, at Villiers, on the 
field of battle, Nov. 30, 1870, and brought to the ambulance of La Salpêtrière, 
the same evening about nine o'clock. A buUet had traversed his skull^ 
piercing it through and through ; one of the orifices was situated on the upper 
part of the forehead, a little to the left of the médian line ; the other, on the 
right side, about the middle of the pariétal bone. The cérébral substance pro- 
truded, like a mushroom, through the last-named orifice. ïhe temporal région 
and the upper eyelid of tlie right side were ecchymosed and tumefied ; pro- 
fouud coma. December 3rd, somnolence ; the patient, when iuterrogatecl 
sharply, mutters some iiiarticulate sounds ; he puis out the tongue perfectly, 
when told ; déglutition proceeds with ease. Almost complète hemiplegia is 
found to exist, wiUi flaccidity of the muscles of the members of the right side. 
Erom time to time, without provocation, a sort of spasmodic contraction 
occurs in the superior member of this side, cansing momentary pronation of 
the arm. ïhe diaphragm seems to be also, from time to time, the seat of 
analogous contractions. The respiration, irregular at tiiues, is calm, without 
stertor. Therc is no déviation of head, or eyes. The labial commissures are. 
not (Irawn to one side. Seusibility appears mucii bluntcd over ail parts of the 
body. No vomiting. Puise vcry fréquent, 140. ]3ecember 4tli (fiftli day), 
same state as the previous day, but the somnolence is more intense than- 
yesterdciy; contractions of the facial muscles are induced with difiiculty, on 
forcibly pincliing ïhe skin. Livoluntary passage of urine and fœces. Skia 
warm, covered with perspiration; axillary température 41° C. The commence- 
ment cf an eschar is obseroed on the right gluteal cminence (Jhe parali/sed side) ; 
nothinrj of the Icind exists on the left. On the inner surface of the rirjlit thigh, 
a little above the knee, on a point where the flexed left knee seems tohave cxercised 
a ralher prohnged fressure during the night, a bulla is found, about the size of 
an alniond,full of a lemon-coloured liquor and surrounded bg an ergthematous 
zone, of little extent. The left knee, in tlic part where the i)rcssure must bave 
bcen, shows no trace of crythema or of epidermic élévation. The patient 
ôuccumbed on the 5th December. 

Autopsg. — The two cérébral hcmisphcrcs, at their middic and superior parts. 



BED-SOEE IN CEREBEAL LESIONS. 77 

The erythema, in ail cases of this kiud, usually shows itself frora 
the second to the fourth day after the attack, rarely sooner, some- 
times later. It affects a peculiar position. It is not in the sacral 
région, so commonly invaded in cases of spinal affection, that it 
develops, nor on any point of the médian parts, but towards the 
«entre of the gluteal région, and, most usually, if there be unilatéral 
lésion of the brain, exclusively on the side corresponding with the 
hemiplegia. (Fig. 3.) 




FiG. 3. — Gluteal escliar of the paralysed side lu a case of apoplexy, consé- 
cutive ou hœmorrhage : a^ mortified portion ; b, erythematous zone. 

On the morrow or after-morrow, the bullous éruption and then 
in the points corresponding to the internai extreniities of the anterior and 
posterior marginal convolutions, are transformed into a confused mess, partly 
reddish, where little dissemiuated clots are found hère and there ; partly bluisli 
(slate-coloured). Ou a transverse section it is found that the softening 
extends to the centrum ovale (majus) of Vieussens, to the vicinity of the 
latéral veutricles, which however it does not attain, even on the left side, where 
the focus of the enccphalitis is much more extensive, in ail directions, than 
on the right. The optic tlialami and corpora striata are perfectly normal. In 
the vicinity of the softcned parts of the brain, the dura mater is covered with a 
ueo-merabrane, of fibrinous character, and purulent in parts. The cranium 
is found to be fractured in several parts, in the neighbourhood of the orifices 
which gave passage to the projectile. 



78 " DECUBITUS OMINOSUS : " OMINOUS BED-SOEE. 

the ecchymotic blotch make their appearance on the central part of 
the erjthematous patch, tliat is, about two inches from the inter- 
gluteal fissure, and about an inch and a half beneath a supposititious 
line, drawn fromits upper extremity, perpendicularly to its direction. 
Next, mortification of the derm supervenes in this same point, and 
it rapidly spreads, if the patient survive ; but it is rather rare, on 
the whole, for the acute bed-sore of apoplectic sufferers to reach 
the stage of confirmed eschar. 

It is likewise uncommon to observe, in addition to the gluteal 
éruption, bullse or vesicles developed on the heel, the internai sur- 
face of the knee, and, in short, on the several points of the para- 
lysed lower extremity which may be subjected to a slight pressure. 

I should not omit to point ont to you that, according to my 
observations, this skin-atfection appears but very exceptionally in 
cases which are to hâve a favourable termination; its appearance 
therefore constitutes a most inauspicious sigu. We might, in fact, 
call it decuhlius ominosus, or omïnoiis led-sore, by way of distinction. 
This symptom, I repeat, is rarely deceptive, and as its existence may 
be discerned from the first days, it consequently acquires, as you 
will understand, a great value in doubtful cases. The very marked 
lowering of the central température, beneath the normal rate, ob- 
servable at the outset of au attack, is to my knowledge the only 
sign that can rival the preceding, in cases of sudden hemiplegia. 

The circumstances in which acute bed-sore of apoplectic patients 
develops, evidently do not permit us to refer to the intervention 
of pressure on the parts where it appears, as the only élément in 
its production. The pressure is the same on both naies, but the 
éruption is exclusively produced, or at least always prédominâtes in 
that of the paralysed side. Many a time I was careful to 
niake the patient repose upon the non-paralysed side, during the 
grcatcr part of the day, and this précaution lias not in any way 
modified the production of the eschar. Besides, what, in such a 
case, could be the influence of a pressure which is only in opération 
for two or three days ? Nor can the irritating contact of urine be 
given as the cause. In several cases, I hâve had this liquid drawn 
off hour by hour, day and night, during tlie whole tiine of the 
discase, in order to avoid as mucli as possible the irritation of the 
skin of the seat, and in spite of every care, the eschar was produced 
in accordance witli the rulcs I hâve indicated. 

What may be the organic cause of this singular trophic lésion? 



ACUTB BED-SOEE OP SPINAL OEIGIN. 



79 



I was long under the impression that this lésion should be con- 
sidered as one of the effects of ueuro-paralytic hypersemia, wliich 
betrays itself always, in a more or less prominent manner, you are 
aware, in members struck with hemiplegia of cérébral origin^ by a 
comparative élévation of température. But this hypothesis is, as 
we shall see, open to a number of objections. The facts which will 
be set forth^ as we proceed, render it probable that we must hère 
recognise the irritation of certain régions of the encephalon, which, 
in the normal state, are believed to exercise a more or less direct in- 
fluence over the nutrition of différent parts of the external tégument. 
B. Of acute bed-sore of spinal origin. When acute bed-sore 
appears under the influence of a lésion of the spinal cord, it shows 
itself in the very great majority of cases in the sacral région — and 
consequently above and internai to the chosen seat of eschars of 
cérébral origin. Hère it occupies the médian line and extends sym- 
metrically, ou either side, towards the adjacent parts. (Fig. 4.) It 




PiG. 4. — Escliar of the sacral région in a case of partial niyelitis occupjiug 
tlie dorsal région of the spiual cord : a, mortified portion ; b, erythematous 
zone, 

may, indeed, happen that only one side will be affected — in the case, 



80 TBAUMATIC MYELITES. 

for instance, \\'liere a latéral half of the cord is alone engaged, and 
tlien the cutaneous lésion frequently shows itself on the opposite 
side of the body from the spinal lésion. 

The influence of attitudes hère plays an important part. Thus 
it is customarj wheu the jiatients are so placed as to repose on 
the side, during part of the day, to find, besides the sacral eschar, 
vast necrosive ulcérations developing on the trochanteric régions. 
It is also common enough to see, contrary to what happens in 
cérébral cases, that the différent parts of the paralysed litnbs which 
are exposed to even slight and brief pressure, as the ankles, heels 
and inner surface of kuees, présent lésions characteristic of acute 
bed-sore. Eschars may also show themselves, but indeed very rarely, 
on a level with the apex of the scapula, or over the olecranon 
process.i 

Speaking generally, we may say that the spinal lésions which 
produce acute bed-sore are also those which give rise to rapid 
muscular atrophy and to other disorders of the same class. The 
almost simultaneous developmeut of thèse différent consécutive 
affections raakes it seem probable, already, that they hâve a common 
origin. 

It behoves us to remark, however, that this rule is far from being 
absolute. As a matter of fact, it is a characteristic of certain spinal 
affections that rapid muscular atrophy is developed without being 
accompanied by eschars ; whilst there are others, on the contrary, 
where the eschars may be produced without the nutrition of the 
muscles in the paralysed limb being affected. This is, in truth, a 
fact of great interest from the stand-point of pathological physiology, 
and one which we shall take care to bring into prominence. 

(Fig.4)- 

{a) We will mention, in the first place, the traumatic lésions of the 
spinal cord, those in particular which resuit from fractures or luxa- 
tions of the vertébral column. Xumerous cases of this kind, 
recorded by Bright,^ Brodie,^ Jeffrey s,^ Ollivier (d'Angers),^ 

' W. Clapp, ' Proviuc. Mcd. and Surg. Journal,' 1851, p. 322, and Gurlt, 
■lue. cil., p. 110, Ko. 76. 

2 II. Briglit, ' Report of Médical Cases,' t. ii, pp. 3S0, 432, London, 1821. 

* ]?. Brodic, ' Medic.-Ciiirurg. Transactions,' p. 148, t. ii, 1836. 

•• JcflVeys, "Cases of fractured spine," in 'Loudoa Med. and Surg. Journ.,' ' 
July, 1S2G. 

•* Ollivier (d'Angers), loc. cil., t. i. 



TlîAUMATIC MYELITES. 81 

Laugier,! Gurlt/ and sorae others/ show with what rapidity sacral 
eschars may be produced in sucli cases. In order to enablc you to 
form distinct ideas, in relation to tliis^ I shail request permission 
to relate briefly some of thèse cases. 

In one case, reported by Dr. Wood^ of New York,^ there was 
fracture of the seventh cervical vertebra, resulting from a fall down 
stairs ; death took place four days after the accident. From the 
second day, redness of the sacral région was noticed, and a bulla 
formed at the coccyx. Hœmaturia super veued on the third day. 

A fall from a height determined complète diastasis of the sixth 
and seventh cervical vertebnic ; death supervened sixty hours after 
the accident, and^ at that period, a vvell-marked bed-sore was 
already visible. This fact is recorded by Dr. Biichner, of Darmstadt.^ 

One of Jefl'rey's cases relates to the fracture of the fourlli dorsal 
vertebra ; a coniirmed eschar occupied the sacral région, from the 
fourth day. The eschar supervened three days after the accident, 
in a patient whose historyhas been narrated by Ollivier (d'Angers), 
on the authority of Guersant, and wlio had received a bullet in the 
body of the eighth dorsal vertebra. 

Another case, given by Jeffreys, is particularly worthy of interest, 
The patient had falleii, from a ladder, a height of twenty-iive feet. 
On post-mortem examinatiou it was found that the bodies of the 
seventh and eighth dorsal vertebrœ were broken in several pièces, 
and had been niuch displaced. On the day of the fall, the skin 
was cold, and the puise barely perceptible. Ail the parts below 
the fracture were deprived of sensibility and motion. Next day, 
there were continuai érections ; " then supervened jîhlyctœnse in 
the région of the sacrum," and, on the same day, "^ the patient 
recovered his sensibility." I point out this last feature to your 
attention, because many authors hâve endeavoured, very erroneouslv, 
as you see, to raake anœsthesia play an important part in the patho- 
geny of acute bed-sore of spinal origin. The persistence of sensibility, 
in the parts situated below the lésion, is also marked out, in a more 

' Laiigicr, "Des Icsions traumatiques de la moelle épinicre," 'Thèse de con- 
cours,' Paris, 1848. 

^ E. Gurlt, 'Handbucli derLehrc voii deu KnocbeubrûcheD/ 2 Th.i. Liefer 
Hainm. 1864. 

■'' See an intercstiiig cîiapter on this subjcct in Herr Saniuel's work, loc. cit., 

P- 239- 
■* Gurlt, loc. cit., Tableau No. 97. ^ Gurlt, loc. cit.. No, 86. 

G 



82 TRAUMATIC MYELITES. 

or less explicit manner, in a case recorded by Colliny,! relating to a 
fracture of the seventli cervical vertebra, wliere the eschar appeared 
on the fourth day, as well as in a case meutioned by Ollivier 
(d'Angers)/ wliere tliere was fracture of the twelfth dorsal vertebra. 
The eschar, in the latter case, made its appearance on the thirteenth 
day. 

It is useless to multiply thèse examples, for ail surgeons agrée in 
ackuowledging that the rapid formation of eschars is one of the 
most common of the phenomena consécutive on spinal lésions 
resulting from fracture with displacement of vertebrse. According 
to Gurlt, vi^hose opinion as regards tliis subject is based on the 
study of a very large number of observations,^ it is from the fourth 
to the fifth day after the accident that the first symptoms of acute 
bed-sore most usually commence to appear ; but they may, as we 
hâve just seen, set in much earlier, as on the second day, and even 
sooner. It seems, and the remark lias been made by Brodie, that 
the production of eschars occurs early in proportion as the lésion 
affects a high point of the cord. On the other hand, it would resuit 
from the statistics drawn up by J. Aslihurst that nutritive troubles 
become fréquent in proportion as the wound is lower down. Thus, 
according to this author, eschars were only observed in three cases, 
after lésions of the cervical région (being 1/41 per cent.) ; twelve 
times (or 9/23 per cent.) for the dorsal région, whilst as regards 
the lumbar région, the proportion rose to 1 3 per cent, (seven cases).'* 

Priapism, clonic convulsions of variable intensity, supervening in 
the paralysed members, either spontaneously or induced, tonic 
convulsions coming on in paroxysms — ail those symptoms, which 
usually reveal a state of irritation of the cord and méninges, hâve 
been many times mentioned among the phenomena which, in 
fractures of the vertébral column, précède, accompany, or closely 
folio w the precocious formation of eschars. 

In such circumstances, as we havc already seen, ansesthesia of 
the parts smitten with motor-paralysis, is not a constant fact. As to 
the remarkable élévation of température of which thèse parts some- 

' Quoted by Ollivier (d'Angers), loc. cit. 

-' Scnsibility was also preserved in Dr. Biicbner's case, quoted above, where 
tbe eschar appeared bcfore the close of the tliird day. 

2 Sec Gurlt, loc. cit., p. 94, analysis of 270 cases. 

* J. Aslihurst, " Injuries of the Spine, with analysis of nearly 400 cases," 
Philadelphia, 1867. 



TRAUMATIC HEMIPAEAPLEGIA. 88 

tiines become tlie seat in conséquence of vaso-motor paralysis,^ it 
cannot now be ascertained whether it was then présent or not^ tbe 
attention of the observers not having been drawn to this particular 
phenomenon, We sliall note, on the contrary, as a symptom which 
shows itself frequently at the same time as the acute bed-sore, the 
émission of sanguinolent urine, alkaline in reaction, and sometimes 
purulent. This is a fact to which we shall hâve occasion to revert. 
Necroscopical examiuation, hitherto, has not, in gênerai, revealed 
anything in connection with spinal lésions which can be considered 
peculiar to the cases where rapidly developing eschars are produced. 
We frequently, however, find mention made of altérations of the 
spinal cord, which place beyond doubt the existence of an iuflam- 
matory process ; the présence of purulent infiltration, and even 
the formation of abscesses in the midst of the softened parts, hâve 
been observed in several instances. 

h. The study of cases of hemiparaplegia, consécutive on wounds 
involviug only a latéral half of the spinal cord, may furnish useful 
information concerning the pathogeny of acute bed-sore, and of 
some other trophic disorders of spinal origin. We learn, from the 
experiments of M, Brown-Séquard, that, after wounds of this kind, 
there supervenes in animais motor-paralysis of the lower extremity, 
on the same side with the lésion. The limb présents also a more or less 
marked degree of exaltation of tactile sensibility, and it likewise 
offers a notable élévation of température correlated with vaso-motor 
paralysis. The opposite limb préserves, on the contrary, its normal 
température and power of motion, whilst the tactile sensibility is 
much lessened, and may even be extinct. Ail thèse particulars are 
exactly reproduced in man under analogous circumstauces. In his 

' In a case of fracture of the vertébral columu iu the dorsal région, observed 
by J. Hutchinson, ou the second day after the accident, the température of 
the feet, taken at the iuner ankles, rose (to ioi° F., or) above sS'^ Cent. In 
the normal state, accordiug to observations made in London Hospital, by 
Dr. Woodman, the thermometer placed between the two first toes gave au 
average of 27"5° C. (8i'5° E.), the maximum being 34'5° C. (94° F.), and the 
minimum 2i"5° C. (70° F.). See J. Hutchinson, "On Fractures of the Spine," 
in ' London Hospital Reports,' t. iii, 1866, p. 363. See also H. Weber and 
GuU, in 'The Lancet,' Jan. 27, 1872, p. 117. Clinical Society of London. 
[See also Mr. J. W. Teale, "Caseof llemarkable Elévation of Température ' 
after injury of the spine, iu a young lady, where 122° F. (50° C.) is stated to 
hâve been observed, 'Lancet,' 1875, p. 340; and J. Hutchinson, "On the 
Température and Circulation after Crushing of the Cervical Spinal Cord," 
' Lancet,' 1875, pp. 714, 747.] (S.) 



84 TEAUMATIC HEMIPAEAPLEGIA. 

case^ as iu that of animais, vve may also find différent trophic dérange- 
ments supervening, which appear almost simultaneously, and whicli 
are ail manifestly due to spinal lésion. Among the nutritive lésions 
of tins kind observed in man^ we would especially point out the 
rapid diminution of the (faradaic) electrical contractility of the 
muscles, soon followed by atrophy, — a particular form of arthro- 
pathy to which I shall refer in a few moments — and finally, acute 
bed-sore. It is a remarkable thing that, whilst the arthropathy 
and muscular atrophy are to be found in the limb on the same side 
with the lésion, the eschar seems to prefer, as we hâve already re- 
marked, to show itself on the member of the opposite side, where 
it occupies the sacral région, and the gluteal, in the immédiate 
neighbourhood of the former. This peculiar disposition of che 
eschar in relation to the seat of the spinal lésion is, according to 
what M. Brown-Séquard lias told me, a constant fact in the case 
of animais; in man, it has already been several times observed. 
As an example of the class, I shall briefly cite the following facts : 
A man, aged twenty years, whose history has been related by M. 
Vignes,^ received on the back of the thorax, between the ninth 
and tentli dorsal vertebrœ, a sword eut which, to judge from the 
symptoms, injured the left latéral half of the spinal cord chiefly. 
Motor paralysis immediately ensued, which, at first affecting both 
the lower extremities, appeared from the next day to be almost 
entirely confined to the left leg. Hypersesthesia is very manifest 
in the latter member ; the right limb présents, on the coutrary, a 
well-marked obnubilation of sensibility, whilst the power of motion 
has nearly quite returned. The symptoms showed rapid improve- 
ment up to the twelfth day after the accident ; on that day it 
was remarked that, without perceptible cause, the left leg, still more 
sensitive than in the normal state, had increased in volume, and 
also that in the left knee-joint there had accumulated a quantity 
of fluid sufficient to kecp the patella raised half an inch above 
the condyles. Two days later an eschar was observed occupying 
the right latéral ])art of the sacrum and right gluteal région. 

The case recorded by M]\l. Joflroy and Salomon,- of onc of Dr. 
Cusco^s patients, which was recently communicated to the Société 
de Biologie, rei)roduces, as it were, the foregoing case, cvcn in its 
suiallest détails. In the former, as in the latter, after a traumatic 

' Brown-Séquard, 'Journal de la Physiologie,' &c., t. iii, p. 130, 1863. 
2 ' Gazette Médicale de Paris,' Nos. 6, 7, 8, 1872. 



TEAUMATIO HEMIPAEAPLEGIA. 85 

lésion affecting one latéral half of the cord in tlie dorsal région, 
we find motor paralysis supervening in the inferior extremity that 
corresponds to the injured side; this limb présents a notable aug- 
mentation of température — a fact not mentioned by Vignes, though 
probably présent — and manifest hypersesthesia; whilst the opposite 
limb, unhavmed in its motor functions, offers a remarkable diminu- 
tion of ail kiuds of sensibility whilst preserving the normal tem- 
pérature. In addition — and this is the point which we désire to 
put especially forward — shortly after the accident, and without any 
appréciable cause, there supervened an arthropathy in the knee of 
the paralysed limb, whilst, in the vicinity of the sacral région, the 
nates of the member deprived of sensibility but not paralysed in 
motion, became the seat of an eschar.^ 

' On account of the iuterest couuected with it, we sliall mentiou the principal 
détails of this case. 

The patient, jMartin, aged about 40 years, was stabbed wiili a poignard, in 
the night of the i.^-iôth February, 1871. The weapon entercd at the third 
dorsal vertebra. The direction of the woiind is downward, backward, and to 
the right. Having been brought to hospilal immediately ai'tcr the wound, it 
was ûbserved that, even then, the left inferior extremity was completeiy stricken 
with motor-paralysis, whilst the corresponding member on the other side showed 
nothing of the kind. February i6th, in the morning, the foUowing note was 
made : — Left lower extremity, complète motor-paralysis. The limb is per- 
fectly flaccid ; no trace of contraction, or rigidity, no spasmodic movements, 
nor subsultus. Ou the contrary, sensibility appears in the same limb to be 
€xaggerated in ail its modes ; the least touch of the skin, especially near the 
foot, causes pain. Pressure lias the same effect. A slight pinch or a tickie 
is followed by very painful sensations. Finally, the contact of a cold surface 
also produces painful sensations which the patient compares to those producible 
-by a séries of prickings. Right lower extremity : ail the voluutary move- 
ments are perfectly normal, but ^;er contra, the sensibility is almost completeiy 
destroyed. Complète analgesia; sensitiveness to touch almost null. The 
contact of a cold body is marked by an obscure duU prickling sensation. The 
insensibility is not limited, on the right, to the lower limb ; it ascends to a level 
with the nipple. The urine and fseces passed involuntarily. 

February 24th (eighth day). — The same phenomena are observed; in addition 
it is noted that the left (motor-paralysed) limb is warmer than the right. 
The patient com plains of a sensation of constriction or rather of compression 
at the base of the thorax. 

Mardi 5th (seventeenth day). — The patient complains of troubled sight: the 
•left pupil is more contracted than the right, and the vessels of the left eye are 
more volumirious and more numerous than those of the right eye. The 
évacuations hâve again become voluntary, for two days past. The state of the 
lower extremities is still unchanged. 

March i3th (twenty-fîfth day). — The right nates, siuce yesterday, lias been 



86 TEAUMATIC HEMIPAEAPLEGIA. 

I take the following case from an interesting work by Herr W. 
Millier •} in this instance the artliropathy is not mentioned ; on the 
other hand, we fmd mention of rapid wasting of the muscles of the 
paralysed limb, preceded for several days by a well-marked diminu- 
tion of faradaic contractiliiy. In ail other matters, Miiller's ob- 
servation is in conformity with those of MM. Yigucs and Joffroy. 
The case is that of a woman, aged 21, who received a stab with a 
knife in the back, at the fourth dorsal vertebra ; the weapon, as the 
autopsy demonstrated afterwards, had completely divided the left 
latéral half of the spinal cord, two millimètres above the third 
dorsal pair. On the very day of the accident complète paralysis and 
hyperœsthesia of the left lower extremity was observed ; the opposite 
limb was anœsthetic, but not paralysed. On the second day it was 
found that the muscles of the paralysed member and those of the 
lower part of the abdomen gave no reaction under the influence of 
faradaic stimulation, whilst, in the homologous parts of the opposite 
side, the electrical contractility remained normal. On the eleventh 
day an eschar was formed, occupying the sacral région and extend- 
ing to the right gluteal eminence. On the same day, it was remarked 
that the paralysed limb had notably wasted away, measuring about 
two inches less in circumference than the ansesthetic member. Death 
occurred on the thirteenth day. On a post-mortem examination, 
tlie borders of the spinal wound appeared tumefied, and of a reddish- 
brown colour ; a thin purulent layer covered it. Below the wound 
the left latéral column, throughout its whole length, offered the 
anatomical characteristics of descending myelitis. 

The simultaneous appearance of différent trophic disorders noted 
in thèse cases, and in some others of the same kind, seem to indi- 
cate a common cause. This cause, to ail appearance, is nothing 
tlie scat of vivid redness, aud tlie epidermis bas already fallen off from a part 
of the erythematous patch. 

March i4th. — The derm is denuded to tlic size of a crown-piece on tlie 
ri"-bt nates, near the sacrum : it is also ecchymosed (acuie bed-sore). On 
Feb. 24th, it had been already remarked that some pain was felt when the 
left knec (motor-paralyscd limb) was moved ; to-day, it is noted that this 
joint is swollcn and red, and that it is, besides, the seat of spontaneous 
pains, cxaggeratcd on movcment (spinal artbropatliy). 

March 24th. — An ulcération, this day covered with granulations, lias formcd 
on the right nates, on a levcl with the ecchymosed patch. The swcUing, redness, 
aud pains havc alniost completely disappeared from the left knee. 

1 W. Millier, "Bcitriigc zur patiiologisch Anatomie und Physiologie des 
nienschlichcn lliickenmarkes," Leipzig, 1871. Obs. i. 



SPONTANEOUS MYELITES. 87 

other than the extension to certain régions of the inferior segment 
of tlie cord, of the inflammatory action originally set up in the 
immédiate vicinity of the wound.^ 

That being admitted, it would seem legitimate, relying on the facts 
stated in the preceding lecture, to assign the rapid and gênerai 
atrophy of the paralysed muscles, noted in Herr Miiller's case, to the 
invasion of the anterior cornu of the grey substance throughout 
the whole extent of the cord, whence nerves are given forth to the 
paralysed muscles; the invasion in question taking place either 
progressively by direct downward propagation ; or indirectly by the 
latéral columns. Tins lésion of the anterior cornu we shall mention, 
in a moment, to explain the development of the arthropathy de- 
scribed in the observations of Viguès and Joffiroy. Now, with re- 
spect to the eschars, their appearance on the side opposite the spinal 
lésion tends to establish that the nerve-fibres (whose altération, 
under such circumstances, provokes the mortification of the external 
tégument) do not follow the same course as those which influence 
the nutrition of joints and muscles, and that they, on the contrary, 
decussate in the cord in the same manner as the nerve-fibres sub- 
serving the transmission of tactile impressions. 

Another item of information which we get from cases of hemi- 
paraplegia consécutive on a unilatéral lésion of the spinal cord, is 
this, namely : acute bed-sore may show itself independently of ail 
neuroparalytic hypersemia, since we observe it forming upon that 
side of the body where the vaso-motor nerves are not afiected. 

c. I shall now mention the case where myelitis results, not, as in 
the preceding instance, from a wound or attrition of the spinal 
cord, but from indirect traumatic influence, such for example as an 
effort made in raising a weight. Acute bed-sore may, in cases 
of this kind, be produced as rapidly as though there had been frac- 
ture of the vertébral column, as the following fact recorded by Dr. 
Gull demonstrates : 

A man, aged 35, by trade a labourer in the London Docks, 
felt, after lifting a load, a sudden pain in his back. He was 

^ In a woik, recently published, I hâve endeavoured to establish that, after 
wounds of the spinal cord, irritative lésions such as hypertrophy of the axis- 
cylinders, prolifération of myelocytes, &c., may be observed at some distance 
from tlie spinal wound, above and below it, scarcely twenty-four hours after 
the accident. Charcot, " Sur la tuméfaction des cellules nerveuses, motrices, 
et des cylindres d'axe des tubes nerveux dans certains cas de myélite," m 
'Archives de Physiologie,' No. i, 1872, p. 95. Obs. i. 



88 PATHOLOGY OF BED-SOEE OF SPINAL OKIGIN. 

able to walk to liis home, about a uiile off. Ou tlie morning of the 
second day after, bis lower limbs were completely paralysed ; two 
days later, or four days after the accident, au escbar bad begun to 
form on the sacral région, and the urine which flowed from the 
bladder was ammoniacal. The patient succumbed ten days after 
paralysis bad set in. At the post-mortem examination, it was 
noted, after careful scrutiny, tbat the boues and ligaments of the 
vertébral column presented no lésion ; in the neighbourhood of the 
iîfth and sixth dorsal vertebra3 the spinal cord was transformed 
throughout its whole breadth iuto a thick liquid, rauco-purulent 
in appearance and in colour both brown and greenish.^ 

FoUowing the example of traumatic myélites, spontaneous acute 
myelitis also very frequently détermines the precocious formation of 
sacral eschars, principally when it sets in suddenly, and when the 
évolution is rapid. In order not to enter on lengthy détails, in con- 
nection with tins matter, I shall confine myself to indicating some 
-examples illustrative of this class of cases. The sore bas been 
noticed on the fifth day in a case reported by Mr. Duckworth,^ on 
the sixth day in the case of a patient under the care of M. Woilliez, 
which M. Joffroy bas communicated to mer, on the ninth day in an 
observation of M. Engelken, on the twelfth day in auother case 
related by the same author;"^ finally, in a case of cervico-dorsal 
meningo-myelitis, published by MM. Voisin and Cornil, the eschar 
formed on the sixth day.* Thèse ex amples might be easily in- 
creased. 

Acute bed-sore frequently accompanies hrematomyelia (which 
indeed appears to be, at ieast in a certain number of cases, only an 
accident of central myelitis) ; thus we found it in the case of Duriau, 
already quoted, where mortification showed itself in the sacral région 
only four days after the appearance of the first symptoms.^ 

We may also observe rapid mortification of the skin of the sacral 
région supervening, even in spinal diseases of slow évolution, when a 
new course of active irritation intervenes on a sudden, or when 
acute inflammatory action is suddenly superadded tothe initial lésion. 

' W. Gull, "Cases of Paraplcgia," in ' Guy's Hospital Eeports,' 1858, 
p. 189, Case xxii. 

- 'The Laucet/ 6 Nov., 1869, p. 638. 

^ Loc. cit., ' Patliolocçie der aciiten Myelitis,' Zuiicli, 1867. 

** 'Gazette des Hôpitaux,' 1865, No. 26. 

'' 'Union Médicale/ t. i, 1858, p. 308. 



INFLUENCE OF THE GEEY SUBSTANCE. 89 

Not only tlie exacerbation of partial scleroseci myelitis, but the 
sudden irruption iuto the rachidian cavity of pus emanating from an 
abscess, in the case of a patient suffering from vertébral disease 
may, as I can attest, détermine the ra])id formation of eschars. 
The same resuit would be likewise produced in case a tumour occu- 
.pying the central portions of the cord should, by its présence, pro- 
voke the development of acute myelitis. Several examples of this 
ikind are on record.^ 

If the évidences which we hâve collected hère do not yet allow us 
to construct a pathogenic theory of acute bed-sore of spinal origin, 
they at least sufïice, if I mistake not, to exhibit the principal con- 
ditions of the phcnomenon. Manifestly, we must relegate to a 
secoudary position the influence of pressure ; and also that of vaso- 
motor paralysis which may be completely absent, as we hâve seen m 
relation to the hemiparaplegia resulting from the traumatic lésion of 
a latéral half of the cord. On the whole^ the dominant and ever 
présent fact is the active irritation of a more or less extensive région 
of the spinal cord — mostly showing itself, anatomically, by the 
characteristics of acute or superacute myelitis, and, clinically, by 
the assemblage of symptoms which are assignable to this kind of 
lésion. To explain the production of trophic disorders which issue 
in sacral mortification, hère again it is not to absence of nerve-action 
that we should appeal, but to irritation of the spinal cord. This 
conclusion is in conformity with the expérimental results which show 
that, in animais, the development of gangrenons ulcérations over 
the sacrum do not supervene on ordinary sections of the cord, but 
only in cases where inflammation has been set up in the neighbour- 
liood of the spinal lésion. 

It is scarcely probable that ail the constituent parts of the cord 
are indiscriminately apt, under the influence of irritation, toprovoke 
the development of acute bed-sore. The great frequency of this acci- 
dent in cases of hœmatomyelia, and of acute central myelitis, where 
the lésion occupies chiefly the central régions of the spinal cord, 
seem to designate the grey substance as playing a prédominant part in 
this respect. And this power is no doubt shared in by the posterior 
white fasciculi, for we know that the irritation of certain parts of 
thèse fasciculi has the effect of determining the production not only 

' Aniougst otliers see MacDowel's "Case of Paraplegia," in ' Dublia 
■Quarterly Journal,' 1862. 



90 INFLUENCE OF THE GEEY SUBSTANCE. 

of différent cutaneous éruptions, but also, though rarely indeed, 
that of dermal necrosis.^ 

On the other hand, it is perfectly established that ail portions of 
tlie grey matter should not be indifferently accused ; some of tliem, 
in fact may, as we hâve already suggested, undergo the gravest 
lésions, without acute bed-sore ever supervening. Such are the 
anterior cornua, whose lésions, per contra, hâve, as y ou are aware, 
a most decided influence on the nutrition of muscles and, as we shall 
soon see, on that of joints also. 

Hence it is that sacral eschar is often absent in infantile spinal 
paralysis, and in adult spinal paralysis — diseases wliich are charac- 
terised anatomically by acute inflammatory lésions, System atically 
limited to the area of the anterior cornua ; whereas, those other 
diseases, which affect the skin, dépend upon irritative lésions 
occupying, either the central and posterior portions of the grey 
matter, or the posterior white fasciculi. Trom this particular point 
of view there is reason to recognise, in the spinal cord, the existence 
of two régions endowed with very distinct properties. Now, since 
thèse régions may be affected either separately or simultaneously, 
it follows that, in clinical practice, acute bed-sore and acute mus- 
cular atrophy will sometimes appear separately^ and that they will 
sometimes, on the contrary, coexist in the same individual. 

!From what précèdes, the influence of irritative lésions of the 
spinal cord upon the development of acute bed-sore seems to us 
placed beyond doubt. Herr Samuel has, however, advanced a con- 
trary opinion ; he thinks that the spinal cord does not play any part 
lierein, and that the spinal ganglia or peripheral nerves are alone 
implicated. We shall mention elsewhere the arguments on which 
this theory is based ; but we are now able to point out that it is in 
formai contradiction with what has been noted in the numerous cases 
of traumatic myelitis affecting an elevated part of the cord — the 
cervical région, for instance, or the superior portion of the dorsal 
région — cases where acute bed-sore supervenes in the sacral région, 
and certainly without the direct participation of the spinal ganglia, 
or of the peripheral nerves. The cases of hœmatomyelia, or of 
spontaneous central myelitis, followed by precocious eschars, are 
likewise adverse to the views of Herr Samuel. 

It is not allcged, however, that the irritative lésions of the peri- 
pheral nerves, and pcrhaps also those of the spinal ganglia, may not 
' See ante. Lecture iii, § i, p. 65. 



LESIONS OF NERVES. 91 

sometimes liave the effect of cTeterminiug the rapid formation of 
eschars. No doubt^ the examples published of dermal necrosis 
developed in conséquence of a puncture^ incomplète section, or 
compression of a nerve are rare enough; but many of them are 
thoroughly convincing.^ In connection witli tins, I will relate tlie 
case of a female patient whicli I hâve been recently studying at La 
Salpêtrière. She had, on the left side, an enormous fibrous tumour 
which compressed, in the pelvis, the roots of the ischiatic and crural 
nerves of the corresponding lower extremity. There had resulted a 
paretic state of this member, accompanied by acute pains running 
along the track of the principal nerve-trunks. One morning, shortly 
after the appearance of the first symptoms of compression, it was 
remarked that an eschar had rapidly formed near and to the left of 
the sacral région. The inner surface of the left knee, likewise, in a 
spot which had been pressed upon by the right knee for a considér- 
able time during the night, in conséquence of the attitude of the 
patient when asleep, presented some pemphigoid bullse, full of a 
brownish liquid, which soon gave place to an eschar. jSFothing of 
the kind was developed on the right knee. This is perhaps the place 
to mention that spontaneous zona which, in certain cases at least, is 
very probably connected with the inflammation of some nerve, may, 
according to the remark of Eayer, occasionally issue in the more 
or less deep mortification of the skin. I hâve been often a witness 
to this fact, occurring among the aged persons in this hospital, and 
I hâve been many times able to satisfy myself that pressure on the spot 
occupied by the éruption did not hère play an essential part. As to 
acute bed-sore of the breech, I am much inclined to believe that, in a 
certain number of cases, it should be attributed to an irritative lésion 
of the nerves of the cauda equina. A case recently published by 
M. Couyba, in his inaugural dissertation^ may be cited as one of 
several examples of this class.^ 

' See, amongst receut published facts, a case reported by Dr. W. A. Lanson 
('The Lancet,' 30 Dec, 1S71, p. 913), and two cases of Dr. Vitrac ('Union 
Médicale de la Gironde,' t. ii, p. 127, and 'Revue Phot. des Hôpitaux,' 1871). 

^ Rayer, ' Maladies de la Peau,' t. i, p. 335. 

^ A young private in the Garde Mobile received a buUet-wound, at the 
outposts of Clamart. The projectile had entered near the anterior extremity 
of the tenth rib on the left side, and had emerged on the right side of the 
vertébral column, about three inclies from the spine, on a level with the second 
lumbar vertebra. Paresis, with acute hyperscsthesia of the lower extremities, 
followed. On the right gluteal emiueuce a bulla (which quickly gave place to 



•92 SPINAL AETHROPATHIES. 

III. 

On Ârthroj^athies of Cerehral or Spinal Origin. — Nutritive disor- 
clers consécutive on lésions of tlie nervous centres not uufrequently 
take up their seat in tlie articulations. The varieties presented by 
thèse articular affections, according to the nature of the cérébral or 
spinal lésions from which they arise, hâve led me to establish two 
|)rincipal catégories. 

A. The first comprises arthropathies of acute or subacute form, 
accompanied by tuméfaction, redness, and sometimes by pain of 
a more or less severe character. This form was indicated for the 
first time, if I mistake not, by an American physician, Professer 
jVIitche]_,i who observed it in the paraplegia connected with Pott's 
disease of the vertébrée, in which, however, it is very rare, in my 
opinion.2 It happens more frequently as a conséquence of a trau- 
matic lésion of the spinal cord, as we find from the sufficient évi- 
dence of the cases, above quoted, which hâve been recorded by MM. 
Viguès and Joffroy;'^ A case of concussion of the cord, related by 
Dr. Gull, supplies an analogous démonstration.* 

Acute or subacute inflammation of the joints of paralysed limbs 
may supervene also, in sjwntaneous mijelitis ; as examples of this 
class, I may mention a case reported by Dr. Gull,^ and another case 
which M. Moynier published in the ' Moniteur des Sciences Médi- 
cales^ for 1859. The second case relates to a young man, aged 

an escliar) appeared on the fiftli day after the accident. Tlie escliar exteuded 
in a progressive mauner, so as at last to cover the whole of the sacro-gluteal 
région. Death occurred on tlie niaeteenth da3\ 

Fost-viortem. — A purulent niass covers the anterior and postcrior surfaces of 
the cord, and extends from the cauda equina to the cervical région. The cord 
.itself when examined, first, in the fresh state, next in nunierous hardened 
sections, did not exhibit any altération. On the other liand, a certain number 
of nerve-tubes in the nerve-filaments which form the cauda equina presented 
the auatomical charactcrs of fatfy granular degcneration. — Coiiyba, ' Thèse de 
'Paris,' 1871. Obs. xiii, p. 53. 

' Milchel, 'American Journal of the Médical Sciences,' t. viii, p. 5,1^, 1831. 

^ I liave, however, seen one knee become the seat of a subacute arlhropathy 
in a woniau sufï'ering from paralysis consécutive on Pott's disease. This case 
.'has been recorded in the thesis of M. Michaud, " Sur la méningite et la 
jmyélite dans le mal vertébral," Paris, 187 1. 

•' Loc. cit., pp. 91, 92. 

^ Gull, ' Guy'.s IIos[)ilal Reports,' 3rd séries, t. iv, 1858. Case xxvii. 

* Gull, idem, Obs. xxvii. 



AETHROPATHY OF HEMIPLEGIC PATIENTS. 95 

eigîiteeii, who, after lodging for a long tirae in a darap place, and 
undergoing great fatigue, had presented ail the symptoms of subacutc 
myelitis. Paralysis of motion begau to show itself on the 25th of 
January ; it became complète on the çth Eebruary. On the 23rd 
of the same month, the skin of the sacral région presented an ery- 
thematous patch which gave place to an eschar, on the 5th of Mardi. 
On the 6th of this month, there was severe pain in the right knee, 
which was swollen, and in which the sensation of fluctuation was 
perceptible. In addition, there was painful tuméfaction of the tibio- 
tarsal articulation of the same side. On the çth of IMarch, the 
knee had decreased in size, and on the same day, eschars made their 
appearance on the heels. The autopsy revealed a focus of ramollisse- 
ment sitnated not quite two inches above the cauda equiua. 

l'inally, in a case of central myelitis in a child, having its origiu 
in the neighbourhood of a solitary tubercle sitnated in the cervical 
région of the cord, Dr. Gull records the formation of an intra- 
articular effusion, occupying one of the knees, at the time when the 
paralysis bcgan to invade the lower extremities.^ 

It is remarkable to see thèse arthropathies, consécutive on the dif- 
férent acute and subacute forms of myelitis, frequently forming, when 
the muscles of the paralysed limbs are beginning to waste away, or 
again when an eschar is being rapidly developed on the breecli. 

The artliroimthij of paraplégie patients, first described I believe 
in 1846, by Scott Alison," afterwards by Brown-Séquard, and the 

' Gull, loc. cit.. Case xxxii. 

" Scott Alisoii, " Arthrites occurring in the Course of Paralysis," Note read 
before the Médical Society of Loiidou, Jaii. 16, 1846, 'The Laucet,' t. i, p^ 
276, 1846. It is mauil'estly to the arthritis of paraplégie patients, such as- 
we hâve described it (' Arch. de Physiologie,' t. i), that the note of Dr. AUison 
refers. It is a characteristic of the affection to remain confined to the 
paralysed limbs, aud not to extend to the sound members. The affected joints 
are liot, swollen, aud in some cases painful, either spontaneously or on move- 
ment made. The parts most frequently affected are the knee, elbow, wrist, 
hand, aud foot. This form of artliritis seems to show itself cliiefly in cases 
where the hemiplegia is consécutive on encephalitis or on Inain softeuin."-. 
Two cases, selected from a number of others of the same kiud, and cited as 
examples, deserve to be briefiy recorded liere : 

Case I. — A woman, aged 49 years, who had long enjoyed perfect health 
and had never suffered from any form of arthritic disease, was suddeuly struck 
■with hemiplegia ; some days after, tuméfaction and heat at the wrist of the 
paralysed side set in, and a little later on, the knee and foot of the same side 



94 ARTHEOFATHY OP HEMIPLEGIC PxVTIENTS. 

anatomical and clinical cliaracters of wliicli I hâve made kuown, 
belongs, if I mistake not, to tlie same category. In tliis second 

becarae swollen and painful iu tlieir turn. Tliere was no œdema. ïlie para- 
lysed limbs were rather rigid. 

On fost-mortem examination, partial softeuing of the brain was discovered. 
Eacli rénal pelvis was filled witli little calcul! of uric acid. 

Case II.- — A nian, aged 54, house painter, wlio had experieuced several 
attacks of goût, was struck witli sudden liemiplegia. Soon after the wrist, 
the hand, and the foot, became hot and swollen. ïhe paralysed limbs were 
rigid. 

At the autopsy, the brain appeared softened, and a voluminous blood-clot 
was found iu one of the latéral ventricles. 

Dr. Alison endeavoured to explain the occurrence of arthritis in the course 
of (hémiplégie) paralysis, by showing that " the healthy relation between the 
living tissues and the materials of the blood was disturbed. Two morbid con- 
ditions gave rise to this disturbance, viz., a state of reduced vitality in the 
paralysed parts, and the présence of exciting and noxious agents in the blood. 
In proof of this varions facts were referred to, and the author related two 
singular cases of the iuflammatory red line of the gums foUowing the use 
of mercury, in paralysis of one sida of the face, beiug strictly conQned to the 
paralysed side of the mouth. The paralysed parts were in fact more délicate 
tests of poisons than parts in a state of healtii. In proof of the présence of 
exciting agents in the blood the gouty diathesis of the second case and the 
lithic acid calculi in the pelvis of the kidney of the iirst case, were adduced." 

We, in our turn, would point ont that, most certaiuly, thèse cases are alto- 
gether exceptioual, as regards the question at issue, for most frequently, as may 
be understood froni a perusal of the cases published in our work (' Archives de 
Physiologie,' t. i), the arthritis supervenes in hémiplégie patients as a more or 
less direct conséquence of the cérébral lésion, quite apart from ail influence 
of goût, rheumatism, or other diathetic condition. 

Hence, whilst acknowledging the accuracy of Dr. Alison's clinical descrip- 
tions, I am unable to endorse the pathogenic theory which he bas proposed. 
I am, however, far from denying that the articulations of paralysed members, 
in cases of hemiplegia of cérébral origin, may, as Dr. Alison holds, be par- 
ticularly disposed to become foci of élimination for other agents previously 
accumulated in the blood. I myself communicated to the Société de Biologie, 
at the timc of its occurrence, a case in which this particular disposition was 
very prominent. A woman, aged about 40 years, had been suddenly struck 
with right hemiplegia, three years beforc hcr admission iuto my wards. The 
paralysed limbs were strongly contracturcd now and again, the several joints of 
thèse limbs, the knee espccially and the foot, were the scats of tuméfaction and 
pain. The patient, being aphasie, in a high degrec, it was impossible to ascer- 
tain if she had been previously subjcct to goût or rheumatism. 

At the autopsy, we found a vast ochreous cicatrix, the vestige of a focus of 
cérébral hxmorrhage, situated exterior to the extra-ventricular nucleus of the 
corpus striatum. In most of the articulations of the limbs on the right side, 
which had been hcniiplcgic, the tîiarthrodial cartilages were incrustcd towards 



PATHOLOGICAL ANATOMY. 95 

variety, as well as in the first^ tlie arthropathies are limited to tlie 
paraljsed limbs and mostly occupy the upper extremities. They 
supervene, especially, after circumscribed cérébral ramollissement 
{eu foi/er), ViXià, more rarely, as a conséquence of intra-eucephalic 
hsemorrhage. 

They usually form fifteen days or a month after the attack of 
apoplexy, that is to say, at the moment when the tardy contracture 
that lays hold on the paralysed members appears, but they may 
also show themselves at a later epoch. The tuméfaction, redness, 

tlieir central parts witli deposits of urate of soda, both crystallised and amor- 
plious. The joints of the limbs, on theother side, presented no similar appear- 
ance. Some white striœ, which were fouud on microscopical and microchemical 
examiuation to be formed by urate of soda, were noticed in the kidueys. 

It is undoubtedly most remarkable to find, in this case, that the gouty 
deposit fonns exclusively in the joints of the paralysed members ; but, I 
cannot too ofteu repeat that facts of this kind are exceptional, and, in any 
case, they hâve nothing in common, from a pathogenic point of view, with the 
ordinary arthritis of hémiplégie patients (' Cas d'Hubert,' see Bourneville, 
" Etudes cliniques et thermometriques sur les maladies du système nerveux," 

P-58). 

The merit is due to M. Brown-Séquard of having directed attention anew 
to the arthropathy of hémiplégie patients, and of having determined the 
organic cause, better than Dr. Alisou had donc. He thus expresses himself 
in a lecture published in * The Lancet ' (" Lectures on the Mode and Origia 
of Symptoms of Diseases of the Brain," Lecture i. Part ii, 'The Lancet,' 
July 13, 1861). After having admitted that the painful sensations, such as 
formication and priekling, which are experieuced in the paralysed members, in 
conséquence of a cérébral lésion, resuit generally from a direct irritation of 
the encephalie nerve-flbres, he adds : 

" It is most important not to confound thèse sensations (which are referred 
sensations, like those taking place when the ulnar nerve bas beeu iujured at 
the elbow joint) with other and sometimes very painful sensations in the 
muscles or in the joints of paralysed limbs. Thèse last sensations very rarely 
exist when the limbs are not moved, or when there is no pressure upon thera ; 
they appear at once, or are increased by any pressure or movemeut. They 
dépend upon a subacute inflammation of the muscles or joints, which is ofteu 
mistaken for a rheumatic affection. This subinflammation in paralysed limbs 
is often the resuit of au irritation of the vaso-motor or nutrition nerves of the 
encephalou." 

Before M. Brown-Séquard, and before even Mr. Scott Alison, many phy- 
sicians had already remarked the arthritis of paralytic patients, but without 
bringing out the iuterest connected therewith. Consult R. Dann, ' The 
Lancet,' t. ii, p. 238, 1841. Durand-Fardel, 'Maladies des Vieillards,' p. 131. 
Paris, 1854, Observation, Lemoine. Valleix, 'Guide du Médecin Praticien,' 
t. iv, 1853, p. 514. Grisolle, 'Pathologie Interne,' 2nd édition, t. ii, p. 257. 



96 CLINICAL CHAEACTEES. 

and pain of the joints are sometimes marlcecl enougli to recall the- 
corresponding phenomena of acute articulai rheumatism. The ten- 
diuous sheaths are, indeetl, often affected at the same time as the 
articulations. 

I hâve shown that we hâve hère a true synovitis with végétation, 
multiplication of the nuclear and fibroid éléments which form the 
articular serous membrane, and augmentation in number and volume 
of the capillary vessels which are there distributed. In intense 
cases, a sero-fibrinous exudation is produced, with which are 
mingled, in varions proportions, white blood-corpuscles that may 
become abundant enougli to distend the synovial cavity. The 
diarthrodial cartilages and ligamentous parts hâve not hitherto 
appeared to présent any concomitant lésion perceptible to the naked 
eye. On the other hand, the tendiuous synovial sheaths, in the 
neighbourhood of the affected joints, take part in the inflamma- 
tory process, and appear greatly congested.i 

It is needless to insist upou the interest which pertains to thèse 
arthropathies as regards diagnosis, — articular rheumatism, whether 
acute or su^acute, being an affection often connected with certain 
forms of cérébral softening, and one which, indeed, shows itself also, 
occasionally, after traumatic causes capable of determining shock iix 
the nervous centres. On the other hand, many affections of the 
spinal cord are erroneously attributed to a rheumatic diathesis in 
conséquence of the coexistence of thèse articular symptoms. The 
clinical characters which render it easy to recognise arthropathies 
correlated with lésions of the nervous centres, and which allow them 
to be distinguished from cases of rheumatic arthritis, are chiefly 
thèse : 

1°. Their limitation to the joints of the paralysed members. 

2°. The generally determinate epoch in which, in cases of 

' Cliarcot, " Sur cuiclques arthropathies qui paraissent dépendre d'une 
lésion du cerveau ou de la moelle épinicre," ' Archives de Physiologie,' t. i, 
p. 396, ri. vi, figs. I, 2, 3, 4, 5, 6. Paris, 1868. The arthropaUiy in question 
should apparently not be coni'oiinded with the articular alFcction which lias 
been describcd, in lattcr days, by Ilcrr llitzig of Berlin, " Ucbcr cinc ber 
schwcren llemiplegicn, Aul'trelende Gallcnkafl'cction," in ' Virchow's Arehiv,* 
Bd. xlviii, hft. 3 u. 4, 1869. Tliis spccies appcars, espccially, wlien the hemi- 
plegia is of comparatively old date, and the i)atients havc been ablc lo walk for 
sonie time ; it chiefly occupies the shoulder-joint, and results principally from 
the displacement of the articular surfaces, occasioned by the paralysis of thé- 
muscles which surround the joint. 



ARTHEOPATHIES OP ATAXIC PATIENTS. 97 

•sudden hemiplegia, they raake their appearance on the morbid 
•scène. 

3°. The coexistence of other trophic troubles of the sanae 
•order^ such as eschars of rapid formation ; and (when the spinal 
•cord is involved) acute muscular atrophy of the paraljsed mem- 
bers, cystitis, nephritis^ <S:c. 

B. The type of the second group is to be found in progressive 
locomotor ataxia. Allow me to fix your attention for an instant 
upon this species of articular affection, in which I take a paternal 
interest, ail the more lively because the signification I attached to it 
bas liad to encounter many sceptics. And at first, a word as to 
the clinical characters of the artliropathy of ataxic patients.^ 

This disorder generally shows itself at a determinate epoch of the 
ataxia, and its appearance coincides, so to speak, in many cases 
with the setting in of motor incoordination. 

Without any appréciable external cause, we may see, betweeu one 
day and the next, the development of a gênerai and often enormous 
tuméfaction of the member, most commonly without any pain 
whatever, or any fébrile reaction. At the end of a few days the 
gênerai tuméfaction disappears, but a more or less considérable 
•swelling of the joint remains, owing to the formation of hydarthus ; 
and sometimes to the accumulation of liquid in the periarticular 
serous bursse also. On puncture being made, a transparent lemon- 
coloured liquid has been frequently drawn from the joint. 

One or two weeks after the invasion, sometimes much sooner, 
the existence of more or less marked cracking sounds may be noted, 
betraying the altération of the articular surfaces which, at this 
period, is already profound.- The hydarthus becomes quickly re- 
solved, leaving after it an extrême mobility in the joint. Hence 
consécutive luxations are frequently found, their production being 
largely aided by the wearing away of the heads of the bones which 
has taken place. I hâve several times observed a rapid wasting of 
the muscular masses of the members affected by the articular 
disorder. 

Ataxic artliropathy usually occupies the knees, shoulders, and 

' Cliarcot, " Sur quelques Arthropathies," &c., p. i. ' Archives de Pliys.,' 
t. i, 1868. 

' In some cases the crackiug souuds hâve preceded, by several days, the 
appearance of the gênerai tuméfaction of the member ; but, as a rule, the 
latter is the ûrst symptom observed. 

7 



98 



ANATOMICAL CHAEACTEES. 



elbows ; it may also take up its seat in the hip-joint. The anatomo- 
pathological information wliich we possess respecting it, is as yet 
very imperfect. However, one character is apparently constant, 
namely, the enormous wearing down which is exhibited in a very 
short space of time by the articular extremities. At the end of 
ttiree months, this head of a humérus which I show you, and which 
belonged to a female patient in whom we were enabled to study the 
invasion of the arthropathy, was^ as you may remark (fig. 5), to a 
great extent destroyed. I would call your attention to the fact, 
that you do not find on this spécimen, the bony burr around the 
worn articular surface, which wonld not fail to be présent if this 
were a case of common dry arthritis.i 





Fig. 5. — Upper extremity of a liealtliy liumerus, and of a humérus present- 
ing the lésions of ataxic arthropathy. 



I now place before you in order to establish the contrast, a knee- 
joint also taken from a woman wlio presented the symptoms of 
ataxic arthropathy, but in whom the articular affection was of 
much older date. Besides the wearing down of the articular sur- 
faces which, as in the preceding case, is carried very far, you 
notice hère the présence of foreign bodies, of bony stalactites, and, 
in a Word, of ail the customary accompaniments of arthritis dé- 
formant. Thèse latter altérations, I repeat, were absolutely want- 
ing in the first case. On this account, I am led to believc that they 

^ Compare Charcot, "Ataxic locomotrice progressive, artliropatliie de 
l'épaule gauche. Tlcsultats nccroscopiques," in 'Archives de Physiologie,* 
t. ii, p. 121, 1869. 



CLINICAL CHARACTERS. 99 

are nowise necessary, and that tliey are produced in an accidentai 
maunei'j and to ail appearance chiefly by the more or less ener- 
getic movements to which the patients sometimes continue to 
subject the affected members. 

I wish to confine myself at présent to this indication of the most 
gênerai features of the arthropathies of ataxic patients, for this is a 
subject which I propose to treat hereafter in more détail. What 
I hâve to say will suffice, I hope, to show that the articular 
affection in question is, itself also, the expression of trophic 
disorders directly dépendent on the lésion of the spinal nerve- 
centre. But hère are the principal arguments upon which I base 
my opinion. 

I would point ont, in the first place, the absence of ail traumatic 
or diathetic cause of rheumatism or of goût, for instance, which 
might explain the appearance of the articular disease in the cases 
which I hâve studied. Herr R. Wolkmann^ has said that the arthro- 
pathy of ataxic patients is simply the resuit of the distension of the 
articular ligaments and capsules, in conséquence of the awkward 
manner of walking peculiar to this class of persons. The ca^es, 
which are now numerous, in which our arthropathy affected the upper 
extremities, and occupied either the shoulder or the elbow, are suffi- 
cient to prove that the interprétation proposed by Wolkmann could 
hâve but a very narrow bearing. The influence of a mère mechanical 
cause cannot be invoked, at least not as a principal agency, eveu 
in cases where the arthropathy occupies the lower extremities. I 
hâve, in fact, taken care to point out, supporting my words by oft 
repeated clinical observations, that the articular affection in ques- 
tion is developed at a comparatively early epoch of the sclerosis of 
the posterior columns, and at a time when motor incoordination is 
as yet null, or scarcely manifest. 

The clinical characters of our arthropathy are, besides, really 
spécial. Its sudden invasion, marked by the gênerai tuméfaction of 
the member ; the rapid altérations of the articular surfaces ; finally, 
its appearance at, as it were, a determinate epoch of the spinal 
disease with which it is connected, constitute so many peculiarities 
which are, if I err not, found together in no other articular affec- 
tion. 

But hère is a more direct argument. Holding as we did that 

' Canstatt'â ' Jahresbericht/ 1868-1869, 2 Bel., p. 391. 



dOO PATHOGENT. 

the artbropathy in question is a trophic lésion consécutive on the 
disease of the spinal cortl, we yet could not think of Connecting it 
with any of the common altérations of progressive locomotor ataxia 
— with sclerosis of the posterior columns, posterior spinal menin- 
gitis, or atrophy of the posterior roots of the spinal nerves. On the 
«ther hand, a minute examination of many cases had taught us that 
it was impossible to invoke a lésion of the peripheral nerves. It is 
in the grey matter of tlie anterior cornua of the cord that the start- 
ing point of this curious complication of the ataxia is to be found 
âccording to our belief.' It is not very rare to find the spinal grey 
matter affected in locomotor ataxia ; but the lésion is then generally 
found in the posterior cornua. Now, it was quite différent in two 
cases of locomotor ataxia, complicated with arthropathy, in which a 
careful examination of the cord bas been made ; the anterior cornua 
were, in both cases, remarkably wasted and deformed, and a certain 
number of the great nerve-cells, those of the external group es- 
.specially, had decreased in size, or even disappeared altogether 
without leaving any vestiges. The altération, besides, showed itself 
exclusively in the anterior cornu corresponding to the side on which 
the articular lésion was situated (fig. 6) . It affected the cervical 
région, in the first case, where the arthropathy occupied the shoulder; 
dt was observed, a little above the lumbar région, in the second case 
"which presented an example of arthropathy of the knee. Above 
and below thèse points, the grey matter of the anterior cornua ap- 
peared to be exempt from altération. 

It may be asked whether this altération of one of the anterior 
■cornua of the cord, which microscopical examination reveals, may 
•not be a resuit of the functional inertia to which the corresponding 
member has been condemned on account of the articular lésion. This 
hypothesis must be rejected because, on the one hand, in both of 
our cases, the members affected by the arthropathics had preservcd to 
a great degree their freedom of motion ; and, on the other hand, the 
lésion of the grey matter differed essentially hère from that which is 
produced after the amputation of a member, or the section of the 
nerves supplying it. 

From what précèdes, I hope to havc made it appear at least 

' Sce Cliarcot et Joffroy, "Note sur une lésion de la substance ç;rise de la 
'nioëlle épinicre, observée dans un cas d'art liropathic lice à l'ataxie locomotrice 
progressive," 'Archives de Physiologie,' t. iii, p. 306, 1870. 



AETHEOPATHIES IX PEOGEESSIVE AMYOTEOPHY. lOÎ 

highly probable that the inflammatory process, fîrst developed in the 
postei'ior columns, by gradually extending to certain régions of tha 
anterior cornua of the grey matter was able to occasion the develop- 
ment of the articular affection in our two patients. If the résulta*! 
obtained in thèse two cases are confirmed by new observations, we 












FiG. 6. — J, lliglit anterior coruu. A', Left anterior cornu. B, Posterior 
grey commissure and central canal. C, Anterior médian fissure, a a', An- 
terior external cell-group. b b', Anterior internai cell-group. c', Right 
posterior external cell-group. The correspouding left group (c) is almost 
altogether absent. 

should be naturally led to admit that arthritic affections connected with 
myelitis, and those observed to follow on cérébral softening, are like- 
wise due to the invasion of the same régions of the grey matter of 
the spinal cord. In cases of brain-softening, the descending sclerosis 
of one of the latéral columns of the cord might be considered as the 
starting point of the diffusion of inflammatory work. 

MM. Patruban,! Eemak,^ and quite recently, Herr Rosenthal,^ 
hâve observed in prof/ressive w;^/5t7</ar «//o;j/^j/^ arthropathies 'o'hich 
by their chnical characters are closely allied with those of ataxic 
patients. This is nothing surprising, if we remember that a pri- 
mary or secondary irritative lésion of the nerve-cells of the anterior 
cornua of the spinal grey matter appears^ in the majority of cases, ta- 

1 Patruban, ' Zeitsclirift fur prakt. Heilkunde,' 1862, No. i. 
- Pi.emak, ' Allgemeine mediziuisclie central Zeitung,' Mardi, 1863, 20 st. 
^ Kosenthal, ' Lelirbuch der Nervenkraukheiten/ p. 571. Wien, 1870.. 
See also Benedikt, ' Elektrotberapie,' t. ii, p. 384. 



102 ARTHROPATHIES IN PROGRESSIVE AMYOTROPHY. 

be the starting- point of tlie arayotrophy whicb, in clinical practice, 
is usuaily designated by the name of progressive muscular atrophy. 

Por to-day, gentlemen, I shall stop hère in this investigation, 
which I expect to bring to a conclusion at our next conférence. 



LECTURE IV. 

NUTRITIVE DISORDERS CONSECUTIVE ON LESIONS OF THE 
BRAIN AND SPINAL CORD. (CONCLUSION.) AFFECTIONS 
OF THE|VISCERA. THEORETICAL OBSERVATIONS. 

SuMMAUY. — Viscéral hyper œmïa and ecchymoses consécutive on expé- 
rimental lésions of différent portions of the encephalon, and on 
intra-encephalic hœmorrhage. Bxperiments of Schiff and 
Brown-Séquard : personal observations. Thèse lésions seem ta 
dépend on vaso-motor paralysis : they should form a separate 
category. Opinion of Schroeder van der Kolk, relative to the 
relations alleged to exist hetween certain lésions of the ence- 
phalon and différent forms of pneumonia, and pulmonary tuber- 
cnlisation. Ha-morrhage of the supra-renal capsules in mye- 
litis. Nephritis and cystitis consécutive on irriiative spinal 
affections of sudden invasion, lohether traumaticor spontaneoiis. 
Hapid altération of the îtrine under thèse circumstances ; often 
remarked contemporaneously with the development of eschars in 
the sacral région; ils connection with lésions of the urinary pas- 
sages which are due to direct influence of the nervous System. 
Theory of the pi'^'oduction of nutritive disorders consécutive on 
lésions of the nervous System. Insufflciency of our présent 
Tcnoioledge, with respect to this question. Paralysis of the 
vaso-motor nerves ; consécutive hyperœmia ; trophic disorders 
not produced. Exceptions to the rule. Irritation qf the vaso- 
motor nerves : the conséquent ischmnia, seems to hâve no marJced 
influence on local nutrition. Bilator and secretor 7ierves : 
researches of Ludwig and Claude Bernard ; analogies hetween 
thèse two orders of nerves. Theoretical application of trophic 
nerves. SamueVs hypothesis. Exposition. Criticisms. Con- 
clusion. 

Gentlemen, — The réverbération of lésions of the nervous System is 
Dot felt only in the peripheral parts, in the skin, bones, and muscles. 



104 VISCEKAL ECCHTMOSES. 

tlie viscera themselves may also be influenced by thèse lésions.. 
It is kiiown that certain altérations of the encephalon, especially 
tliose wliich affect the optic thalami, the corpora striata, and par- 
ticularly the différent parts of the isthmus^ whether caused experi- 
mentally, or spontaneously produced, are occasionally followed by 
the manifestation of certain viscéral lésions. 

Thus in some experiments ruade by Professor Schiff^ and by Brown- 
Séquard^ there frequently supervened in the lungs, stomach, or 
kidneysj either simple hypersemia or real ecchymoses^ conséquent on. 
traumatic irritation of the optic thalami, corpora striata, pons 
Varolii, and bulbus rachidicus, &c. Again, nothing is more com- 
mon, as I hâve sliown, than to find in man, in cases of apoplexy 
symptomatic of cérébral softening, but especially in cases of intra- 
encephalic hsemorrhage in foci, patches of congestion and real 
ecchymoses on the pleurse, the endocardium, and the mucous mem- 
brane of the stomach.^ 

What is the reason of thèse singular altérations ? Professor Schiff 
does not hesitate to look on them as being simply the effects of the 
paralysis of the vaso-motor nerves. 

I am very much inclined, for my part, to believe that the patho- 
genic process is hère more complex. Nevertheless, the direct influ- 
ence, so to speak, of neuro-paralytic hypersemia on the development of 
ecchymoses, in apoplectic patients, seems well established by the 
following case which I communicated to the Société de Biologie, 
in 1868. 

A female in La Salpêtrière was struck with apoplexy, followed by 
hemiplegia of the left side, and succumbed a few days after. The 
paralysed members had presented a comparatively considérable in- 
crease of température. At the autopsy, we discovered in the right 
hémisphère a récent hsemorrhagic focus, occupying the corpus stri- 
atum. The epicranial aponeurosis presented on the left, or hémi- 
plégie side, a wine-red colour^ and, hère and there, spots of 
ecchymosis. 

The abnormal colour and the ecchymoses stopped suddenly at 
the médian line. The right half of the epicranium had pre- 

1 Scbiff, 'Gazette Hebdomadaire,' t. i, p. 428. 'Lezioni di Tiziologia 
sperimentale sul systema iicrvoso encefalieo,' pp. 287, 297, 373-. Krenze,. 
1866. 'Leçons sur la Physiologie de la Digestion,' t. ii, p. 433. Florence». 
1867. 

- 'Société de Biologie,' 1870. 

^ 'Comptes Kcndus de la Société de Biologie,' 19 Juin, 1869. Paris, 187a- 



VISCEKAL ECCHYMOSES. 105 

served its customary pallor : no traces of ecchymosis were to be 
found. Spots of ecchymosis were observed in the substance of the~ 
pleurse, of the endocardium, and of the mucous membrane of the 
stomach.^ 

However it be, the viscéral lésions in question differ by important 
characteristics from the affections which form the principal object of 
our studies. Those are congestions and ecchymoses, as we hâve 
said ; the symptoms of inflammation are never superadded without 
the intervention of some accessory cause, a thing altogether unneces- 
sary, as you are aware, in cases of common trophic lésions. We hâve 
consequently grounds for placing in a separate category, at least tem- 
porarily, the congestions and ecchymoses -which make their appear- 
ance consecutively on lésions of difierent parts of the encephalon. 

Again, some authors, Schroeder van der Kolk amongst others,, 
consider that the diff'erent forms of pneumonia, and even of pulmonary 
tuberculisation, which frequently supervene in the course of certain 
encephalic affections, dépend, in such circumstances, on the influence 
of lésions of the brain and medulla oblongata upon the lungs. But 
it must be acknowledged that the cases upon which the alleged' 
connection rests are not yet sufficiently convincing." 

' 'Comptes Eendus de la Société de Biologie,' année 1868. Paris, 1869,. 
p. 213. 

" Schroeder van der Kolk. '' Atropby of the braiu," Sydenham Society,. 
1861. The author dwells on the lact that, according to the statistics published 
in lus Treatise on the Spinal Cord, ail the epileptic patients whose toiigues 
were bitten, succumbed in conséquence of phthisis, pneumonia, or marasmus.. 
He adds that, according to Durand-Fardel, patients attacked by braiu-softening 
almost always die of a pulmonary affection, and lie quotes Eugel's statistics 
which support this view ('Prager Yierteljahaschr.,' vii Jahrg., Bd. iii). He 
refers to the experiments, now of old date, in which Schiff believed he saw,. 
in the rabbit, tubercles (?) developed in the upper lobe of the lung after the 
section of the ganglion of the pneumogastric nerve (' "Wunderlich's Archiv/ 
6 Jahr., 8 heft, pp. 769 et seq.), aud fiually points out that, among tlie observa- 
tions collected by Brown-Séquard in his " Hecherchcs sur la Physiologie de la 
protubérance annulaire" (' Journal de la Physiologie,' t. i), tliere are a certain 
number wherc phthisis and pneumonia occasioued death. Cruveilhier, Andral,,. 
aud Piorry had long siuce noted the prédominant part which, according to them, 
acute j)ncumonia plays in the issue of apoplexies determiued by cerebrali 
softeniiig or hœmorrhagc. 

According to the observations which I hâve collected at La Salpctricre, 
lobular or lobar inflammations of the lungs would be less fréquent, under the 
circumstances, than thèse physicians seem to believe. 



106 HyEMOERHAGE OP SUPEA-EENAL CAPSULES. 

Spinal lésions, as well as lésions of tlie encephalon, may be fol- 
loued by tlie production of viscéral ecchymoses. It will suffice for 
me to remind you that if tlie lumbar cord be wounded with a punc- 
turing instrument, in a guinea-pig, effusion of blood into the supra- 
renal capsules occasionally follows.^ It seems riglit to recall this 
experiraent of Brown-Séquard, because Imman pathology supplies 
us with analogous facts. Quite recently my friend Dr. Bouchard 
bas told me of a case of acute myelitis, observed in Professor 
Béhier's wards, and promptly terminating in death. At the autopsy, 
besides the lésions of partial myelitis, the existence of récent hemor- 
rhagic foci were discerued in the substance of the supra-renal cap- 
sules. 

But, I repeat, congestive and ecchymotic lésions appear to form 
a separate order. On the other hand, the affections of the kidneys 
and of the bladder, to wbich I wish now to call your attention, are, 
by the gênerai bearing of their characteristics, allied to the group 
of trophic lésions, properly so called. 

You are aware that nephritis and cystitis are very common com- 
plications of irritative spinal affections, of sudden invasion, whether 
they be of traumatic origin, or spontaneously developed. 

It bas been long recognised that, after fracture of the vertébral 
column with consécutive lésion of the spinal cord, the urine fre- 
quently undergoes rapid altération. Dupuytren pointed out, as you 
may recollect, that in sucli circumstances the cathéter left in the 
bladder to guard against rétention of urine, became rapidly coated 
with a calcareous incrustation." But it was Brodie especially, who 
called attention to the characters presented by the urine in the case 
of persons stricken with traumatic paraplegia.^ On the eighth, on 
the third, and on the second day, he bas observed the urine become 
alkaline, and exhale a fœtid ammoniacal odour, at the moment of 
émission. Soon afterwards, it contained blood-clots, muco-pus, 
deposits of ammoniaco-magnesian phosphates. It wouid, in fact, be 
easy to gatber from authors a very great number of cases in whicli 
the urine-changes, noticed by Brodie, bave occurred in the first days 
following on paraj)legia, determined by fracture of the vertébral 

' Brown-S6quard, " Influence d'une partie de la moelle cpinière sur les 
capsules surrénales," 'Comptes Rendus de la Société de Biologie,' 1S51, t. iii, 
p. 146. 

- Ollivier (d'Angers), loc. cil., t. i, p. 372. 

^ Brodie, ' Medico-Chirurg. Transactions,' loc. cit. 



NEPHRO-CYSTITIS. 107 

column.^ At the autopsy, in such cases^ more or less advanced 
lésions of purulent nephro-cystitis are found.'" 

But traumatic lésions of this kind are, in gênerai, little suited to 
illustrate clearly tlie relations which exist between inflammation 
■of the urinary passages and altérations of the spinal cord. For it eau 
always be supposed, if strictly considered, that a fall or concussion 
violent enough to produce fracture of the spine, may hâve determined 
the vesico-renal lésions by the same shock. 

It is otherwise when we hâve to deal with an affection^ sponta- 
neously developed in the spinal cord, or with a wound determined in 
this organ by the blow of some sharp weapon. Now, even in 
cases of this kind, it is common to find, a short time after the 
invasion of the paralytic phenomena, a more or less marked modi- 
fication in the constitution of the urine, connected with nephro- 
vesical altérations, not unfrequently of a serious character. I shall 
confine myself to mentioning, by way of example, the following 
facts. 

In one case, previously described, of hemiparaplegia caused by 
a knife-stab the urine became alkaline on the third day, and soon 
after muco-puruleut. Deatli occurred on the thirteenth day. 

At the autopsy, very évident inâammatory lésions were found in 
the kidneys, ureters, and bladder.^ In an analogous case, reported 
by M. Brown-Séquard, on the authority of Dr. Maunder,^ the 
urine was likewise found to be alkaline, a very short time after the 
accident. Cases of this kind are very interesting inasmuch as they 
show that a unilatéral and very circumscribed lésion of the cord 
suffices to détermine a more or less grave and generalised affection 
of the urinary passages. 

Ahke in spontaneous acute myelitis, of sudden invasion, and in 
hfematomyelia, is the appearance of ammoniacal, sanguineous, and 
muco-purulent urine a fact of fréquent occurrence, soon after the 
manifestation of paralytic symptoms. Thus the urine was already 
greatly altered on the fifth day, in the case of acute myelitis, which 

^ See Stanley, ist case. Urine strongly ammoniacal on tlie fifth day; 
2nd case, ammoniacal urine on the fourth day. ' London Medico-Chirurg. 
Trans.,' t. xviii, p. i. Jeffreys : urine ammoniacal and sanguineous, the 
seventh day (Ollivier, d'Angers, loc. cit., t. i, p. 322). 

- Molendrinski, " Bruch des Zweiten Lendenwirbels," Langenbeck's 
*Archiv,' xi Ed., 1869, p. 8,(^9. 

^ Case of W. Millier, see anfe, ' Third Lecture,' p. 86. 

^ 'Journal de Physiologie,' t. vi, p. 152, 1863. 



108 ALTERATIONS OF URINE. 

we hâve quoted from Dr. Duckworth;^ on the sixth day, in tîiat 
given by M. Joffroy.- It was ammoniacal the fourth day, in 
Dr. Gull's patient ; ^ sanguineous the third, and purulent the ninth, 
in a case recorded by Herr Mannkopf.'*' 

In the case of hsematomyelia, recorded by M. Duriau,'' the 
urine was ammoniacal and contained blood-clots the fourth day ; it 
presented the same character the sixth day and became gradually 
purulent in a case reported by Olhvier (d^ Angers) on the authority 
of Monod.^ In this instance^ there was hemiparaplegia, consécutive 
on the présence of a hsemorrhagic focus occupying a latéral half of 
the spinal cord. You will find^ in the work of M. Rayer, the 
description of lésions, frequently grave, affecting the kidneys, the 
rénal pelves, and the bladder, to which thèse changes in the urine 
should be attributed.'^ 

Many of the observations, just cited, contain an item of informa- 
tion the importance of which cannot escape your notice. It is 
mentioned that the urine which until then was normal became, as I 
hâve said, ammoniacal, sanguineous, or muco-purulent, at the very 
time when eschars were being developed on the sacral région, and 
when the electrical contractility was beginning to grow feeble in 
the paralysed muscles.^ 

How are we to understand so rapid a development of the in- 

1 See unie, ' Third Lecture/ p. 88. 

2 Idem, p. 88. 

3 Idem, p. 87. 

'' ' Berliner Klin. Wocliensclirift,' t. i, No. i, 1864. 

5 ' Third Lecture,' p. 88. 

^ Ollivier (d'Angers), loc. cit., t. ii, p. 177. 

"^ Rayer, ' Traité des maladies des reins,' t. i, p. 530 et seq. " Accordinj^ 
to my observations," llayer writes, " iu the diseases of tiie spinal cord, when 
the urine contained iu the bladder is alkaline, it is so, not because of a décom- 
position dilïicult to be explained without atmospheric contact, and in a short 
space of time, but rather by a vice of rénal sécrétion which should be attributcd, 
in most cases, to au inflammatory irritation of thèse organs" 

As regards the description of altérations in the urinary passages, consécutive 
on acute affections of the spinal cord, consult, Engelken, loe. cit., p. 12.. 
Mannkopf, 'Bericht liber die Versanimlung zu ILinnover,' p. 259; and 'Berlin. 
Klin. Woch.,' t. i. Coni])arc, Eosenstcin, ' Nicrenkranklieiten,' 2 Ed., p. 287.. 
Berlin, 1870. 

" Ollivier (d'Angers) liad alrcady remarkcd that, in trauniatic paraplegia^ 
when the urine alters at an carly period the eschars arc found to form rapidlj 
in the sacral région, Loc. cit., t. ii, p. 37. 



THEORETIOAL PORTION. 109 

flammatory lésions of tlie urinary passages after acute affections^ 
spontaneous or tvaumatic, of the spinal cord ? Manifestly, the 
paralytic rétention of tlie urine cannot hère be pleaded^ at least not 
as the sole, nor even as the prédominant, pathogenic élément. 
Neither is it possible to attach great weight to the opinion ^ which 
would attribute the urine-changes, in such circumstances, to the 
introduction of unclean cathéters, carrying vibriones. In point of 
fact, the introduction of vibriones into the bladder could only be a 
chance occurrence, whilst the appearance of ammoniacal, san- 
guineous, and purulent urine, in the course of acute myelitis is, 
like the production of eschars, what may be termed a regular 
fact. 

The notorious insufficiency of the pathogenic conditions just 
enumerated, renders it at least highly probable that there is a direct 
action of the nervous System engaged in the production of the 
affection of the urinary passages which we are considering. The 
cause of this affection, as of the otlier trophic lésions which often 
show themselves at the same time, would therefore be the irritation 
of certain portions of the spinal centre, and more particularly, no 
doubt, of the grey substance. 

Theoretical Portion. 

Gentlemen, — In the foregoing séries of studies, we hâve often 
had occasion to acknowledge that the development of the trophic 
disorders, ensuing after lésions of the nervous System, is not in 
gênerai (contrary to a wide-spread opinion) the conséquence of 
absence of action of différent parts of that System. Ear from that, 
thèse affections would resuit, in our view, from the irritation set 
up, under certain conditions, either in the peripheral nerves or in 
the nervous centres themselves. Tlius, we find ourselves possessing 
a view, which is of primary importance to the pathologist, and you, 
without further explanation, can readily divine the practical déduc- 
tions to which it may guide us. 

But it must next be acknowledged that this wholly empirical 
notion marks only the first step taken towards the scientific know- 
ledge of the phenomena, which observation has allowed us to esta- 
blish. Por, if we know the mode of initial altération and its seat as 

' Traube, ' Munk. Beiiiuer Kliu. Wocbeusch.,' p. 19, 1864. 



110 VASO-MOTOR THEORT. 

well^ there remains yet to be determined^ in tlie first place^ tlie 
means by whicli tliis lésion reacts upon tlie perip lierai parts. 

Evidentlj, this reaction is produced by means of tlie nerves, but 
that also, from a tlieoretical point of view, is an insufficient datum. 
It is necessary to endeavour to be more précise, and to seek what is 
tlie élément, in that pliysiologically complex totality called a nerve, 
by whicli the transmission is operated, and also the mechanism of 
this transmission. 

I approach the question just raised, with an almost absolute 
certainty of not being able to answer it by rigorous arguments. 
Perhaps, I should hâve avoided it, desirous of not wasting your 
valuable time, if I were not convinced that it behoves us at least to 
show the inanity of a theory which professes to résolve it, and 
which to-day enjoys an almost uiicontested sway. 

You are not unaware, gentlemen, of the considérable influence 
which has beeii attributed to the vaso-motor nerves in the explana- 
tion of pathological phenomena. I am far from wishing to ignore 
the fact that a goodly number of thèse phenomena do, indeed, 
directly dépend either on the dilatation or on the contraction of the 
smaller vessels, determined by nervous influence. But in so far as 
the trophic disorders which form the object of our studies are con- 
cerned, I hope that it will not be difficult to show, from a brief 
examiuation, that the vaso-vioior theory is altogether insufficient. 

In order to attain this aira, I am induced to remind you of some 
of the expérimental facts which hâve unveiled the functions of thèse 
centrifugal nerves whose ultimate ramifications go to animate the 
muscular coat of the smaller vessels. I shall, in the first place, 
recall the phenomena noticed when thèse nerves hâve been para- 
lysed in conséquence of complète section, for instance. 

Section of the vaso-motor nerves^ has the immédiate effect of 
producing a paralytic dilatation of the vessels to which they are dis- 
tributed. Ilence results a state of hyperœmia, terracd neuro-pur a- 
lijtic, which has been especially well studied in cases of section of 
the £rreat syrapathctic nerve in the cervical région, but which is to 
be found with almost identical characters after a great number of 
lésions of the nervous centres or of the peripheral nerves. The 
conséquences of this hyperœmia are, from our point of view, par- 

• Tor the physiology and jmtliologj^ of the vaso-molor nerves, consult, 
Vulpian, "Leçons sur ra])parcil vaso-moteur," rceciiillies par C. Carville, 
Paris, 1875 []>lol,c lo Ihe second ediliou). 



NEURO-PAEALTTIC HYPEEiEMIA. 111 

ticularly worthy of interest. You know that the part answering to 
the divided nerve, présents a relative élévation of température, which 
appears solely to resuit from the afflux of a greater quantity of 
blood. You know that throughout the whole extent of the hyper- 
asmic territory an exaltation seems also to ensue of ail the vital 
properties of every élément and every tissue. At least, the sen- 
sitive as well as the motor nerves, and the muscles themselves become 
more excitable,' and the latter préserve, longer than is usual after 
death lias occurred, their proper contractility." Nevertheless, in 
spite of thèse new conditions, — and this is a point which requires ta 
be set promiuently forth, — the accomplishment of the intimate acts 
of nutrition appears to be modified in nothing essential, Thus, in 
the experiments of M. Ollier^, agreeing in that respect with those of 
M. Claude Bernard, there is not found to supervene, in young animais 
after section of the great sympathetic in the neck, either an ac- 
célération or an exaggeration in the growth of the parts of the 
face, even when subjected for months to neuro-paralytic hypersemia. 
Nor does it appear that this hypersemia, hovvever intense or prolonged 
it may be, has ever the effect, save under exceptional circumstances 
to be hereafter mentioned, of determining by itself the development 
of inflammatory action. And if the expérimenter iutervenes and 
applies agents capable of provokiug inflammation, the morbid pro- 
cess determined by this influence goes through its course in the 
hypersemic parts as if under normal conditions ; it offers no spécial 
characters, except, indeed, that the injured parts tend to heal with 
greater promptness. 

,_^^ It is true that, in référence to the latter points, M. SchifF pro- 
fesses a very différent opinion. He affirms, in fact, that changes of 
nutrition originate in the hyperssmic parts, in cases of vaso-motor 
paralysis, under the influence of the slightest local mechanical 
irritant,'^ and that inflammation hère readily takes on a destructive 
character.^ But upon this subject he is in direct opposition to 
MM. Snellen, Virchow*' and O. Weber.^ 

1 Brown-Séquard, ' Lectures on Physiology and Patliology,' Pliiladclpliia, 
1860, p. 1457- 

- Brown-Scquard, hc. cit. Josepb, in ' Ceutralblatt,' 1871, No. 46. 

3 OUier, 'Journal de la Physiologie/ t. vi, p, 108. 

" Scliiff, 'Physiologie de la digestion,' p. 235, t. i. 'Lezioni di Fisiologia,' 
Pirenze, 1866, p. 35. * Schiff, ' Digestion,' t. ii, p. 423. 

c Virchow, ' Cell-pathologie,' 4 éd., p. 158. 

7 O. Weber, ' Centralblatt,' 1864, p. 148. 



113 NEURO-PAEALYTIC HYPERiEMIA. 

In a récent expérimenta besides, Herr Sinitziu states tliat after the 
extirpation of the superior cervical ganglion on one side, the introduc- 
vtion of aslender pièce of glass into the corneaof the same side caused 
raerely a very slight inflammatory reaction, sometimes scarcely notice- 
^able ; whilst on the opposite side, in the selfsame animal, its introduc- 
tion caused, on the contrary, a most active inflammation with purulent 
infiltration of the cornea, iritis, panophthalmia, &c.i M. Claude 
Bernard, indeed, long since pointed out that ablation of the supe- 
rior cervical ganglion appears to retard the manifestation of the 
nutritive disorders occasionally determined in the eye by section of 
the lifth pair of nerves,^ and Herr Sinitzin has arrived at the same 
.results in his experiments. 

Prom this you may perceîve that, contrary to the opinion of 
Professor Schiff, neuro-paralytic hypersemia does not create in the 
parts it occupies, a peculiar prédisposition to the production of 
trophic dérangement. It would even seem that thèse parts are 
better able to resist the action of disorganising causes and that any 
disorder set up there is more speedily repaired than elsewhere. 

In man, so far as this question is concerned, little différence is to 
be found occurring, from what is observed in animais. At ail events, 
«euro-paralytic hypersemia has been seen to persist for a long period 
in parts of the body, as for instance in the face, without any nutri- 
tive disorder ever supervening. M. Perroud has collected a certain 
number of cases of this kind, in a memoir read in 1864, before the 
Médical Society of Lyons. It suffices, indeed, to glance at the 
numerous works which, of late years, hâve been published upon 
Angioneuroses to perceive that nutritive disorders are a rather rare 
accompaniment of neuro-paralytic hypersemia. A new argument may, 
perhaps, be added in support of the thesis which we uphold. It is 
this : The élévation of température, tested by means of a thermo- 
meter, is, we hâve said, a phenomenon indissolubly linkeJ with the 
existence of partial hypersemias of neuro-paralytic origin. Tins 
local hyperthermia should necessarily exist in parts presenting the 
trophic dérangements we havc described, if thèse were really dépen- 
dent on a neuro-paralytic cause. Now, that docs not happcn, as a 
gênerai fact. If a marked élévation of température has been many 
timcs observed in those régions of the body where an éruption of 

» Sinitzin, 'Ccntralblatt:/ 1871, p. i6i. 

^ Claude Bernard, ' Système Nerveux,' t. ii, p. 65, 1865. 



NEUEO-PAKALYTIO HITEE^MIA. 113 

zona, consécutive on neuralgia, or neuritis liad developed ;i on the 
other haud it may besaid that irritative lésions of the péri pheral uerves, 
in tlie conditions when they usually détermine trophic disorders, 
appear to be accompanied rather by a lowering of tlie thermal 
standard than by its élévation. This lowering bas beeu observed 
at every period of the nerve-affection ; it has been noted near 
the commencement/ still oftener in the advanced stages.^ When 
spinal lésions are coucerned, it is true that occasionally the members 
subject to trophic troubles, rapid muscular atrophy, buUar éruptions, 
or eschars, exhibit a more or less marked élévation of température.^ 
But at other times, perhaps in the majority of instances, this phenom- 
enon is absent ; thus it is absent in partial myelitis,^ and in infantile 
paralysis f — the same rule holds good for cases of slow évolution, 
such as, for instance, progressive muscular atrophy.7 

You observe, from what précèdes, that the trophic disorders 
connected with irritative lésions of the nervous centres may, in a 
considérable number of cases at least, occur without that élévation 
of température whicli should, I repeat, be necessarily présent in ail 
cases, if they really originate in hypersemia, consécutive on paralysis 
of the vaso-motor nerves. 

1 Horuer, quoted by 0. Wyss, 'Archiv der Heilkunde,' 1871. See note to 
p. 563. Charcot, ' Névralgie du nerf cubital. Eruption du Zona sur le trajet du 
nerf affecté ; examen thermométrique,' Thèse de Mougeot, Paris, 1867, p. loi. 

- Polet, " Cas de Contusion du plexus bracliial, observé par M. Lanuelougue," 
* Etude sur la température des parties paralysées,' Paris, 1867, p. 7. 

^ Hutchinson, /oc. Cî7. Earle, ' Medico-Chirurg. Trans.,' vol. vii, 1816, p. 
173. Yellowly, ici., t. iii. W. B. Woodmann, in ' Sydenham Society's Traus- 
aclions.' Translation of Wundeiiich, 'On Température in Diseases,' p. 152. 
W. Mitchel, 'Injuries of Nerves,' Philadelphia, 1872, p. 175. In two cases 
of nerve-wounds witli " glossy skin," the région occupied by the trophic 
lésion was from one to two degrees warnier than the corresponding région of 
the healthy limb. But above this point, the thermometer marked ouc degree 
lower than on the healthy limb. H. Eischer, ' Ueber trophische Storungeu 
nach Nervenverletzungen an den Extremitaten," in ' Berliner Klin. Woch- 
enschr.,' 1871, No. 13. The température of theliinbs, ou which the most varied 
trophic disorders occur, is, at first, higher than that of the healthy members, 
afterwards it is relatively lower ; but there are many exceptions to this rule. 

•* Levier, " Cas d' Hématomyélie," loc. cit. ^ Mannkoff, loc. cit. 

^ Ducheune (de Boulogne), loc. cit., 3rd édition, p. 398. 

"^ Landois und Mosler, in 'Berliner Klinisch. Woclienschr.,' 1868, s. 45. 
Eor examples of depressed température supervening after spinal iujury, see J. 
Hutchinson : " Température, &c., after crushing of the cervical spinal cord," 
'Lancet,'pp. 713, 747. 1875. (S.) 

8 



114 NEURO-PAEALTTIC HYPEK^MIA. 

Heuce it follows that neuro-paralytic liypersemia and tlie produc- 
tion of tropliic dérangements are, in ordinary conditions, plienomena 
independent of eacli other. But as we suggested, a little ago, 
there are circumstances in which, contrary to the usual rule^ local 
nutrition may receive a serions blow from tlie mère fact that the part 
has been withdrawn from vaso-motor innervation. This happens, 
as experiments attest, when the whole organism lias been subjected 
to potent debilitating causes. Thus, a vigorous animal has long had 
the great sympathetic nerve divided on one side of the neck ; 
nevertheless, no injury has been experienced in the parts corre- 
sponding to the distribution of the divided nerve. But let the animal 
fall sick, or be deprived of food, then the scène changes immedi- 
ately and we see, says M. Claude Bernard, inflammatory phenomena 
ensue in that side of the face which corresponds with the expéri- 
mental section. On that side, even without the intervention of any 
external agent whatever, the conjunctiva and the pituitary mem- 
brane rapidly begin to suppurate.^ 

It is legitimate to suppose that the animais in which Professor 
Schiff saw trophic lésions supervene, consecutively on neuro-paralytic 
hypersemia, under the influence of the slightest mechanical irritation, 
had been suffering from the debilitating conditions noticed by M. 
Claude Bernard. In man, the same concurrence of circumstances 
ought necessarily to détermine efl^ects analogous to those observed in 
animais, and we may, indeed, question whether some of our trophic 
dérangements are not really produced in this manner. Such is, 
perhaps, the case as regards the acide hed-sore of apoplectic 
patients. Hère, in fact, the gênerai condition is most unfavourable, 
and the gluteal eschar occupies precisely that side of the body which, 
on account of the motor paralysis, présents a relative élévation of 
température, evidently coimected with vaso-motor hypersemia.'-^ 

However it be, this pathogenic interprétation can hâve but a 
very restricted application, for acute bed-sore arising from lésion 
of the nervous centres may appear in many cases, after hemi- 
lateral lésions of the spinal cord for example,^ on parts of the 
body where the vaso-motor innervation is not visibly afl'ected and 
apart from every symptom indicative of great dépression of the 
organism. 

* Claude Bernard, 'Physiologie du Système Nerveux,' t. ii, p. 535, Paris, 
1858. 'Médical Tiincs aud Gazette,' p. 79, t. ii, 1861. 
'■' Sce ante^ Tliird Lecture, p. 76. 3 Hjij_ p_ g^^ 



IRKiTATION or VASO-MOTOR NEEVES. 115 

We hâve now to enquire whether tlie irritation of the vaso-motor 
nerves eau account for the phenomena which are not explained by 
the paralysis of the same nerves. Let us first take expérimental 
irritation. Partial ischsemia, of a more or less intense character, is 
the most prominent resuit of this irritation : it may be carried so 
far that not even a drop of blood flows on pricking the skin.i The 
parts, in which vascular spasm thus impedes the circulation, grow 
pale and cold ; their vital activity decreases ; the excitability of the 
muscles and of the nerves falls belovv the normal standard. - It is 
natural to think that grave nutritive lésions, teuding to necrobiosis 
or to sphacelus, should necessarily resuit froni the prolongation of 
such a state. But it is important to observe that this is commonly 
a question of a temporary phenomenon, lasting at longest for a few 
hours only. For by the very fact of the prolongation of the irri- 
tation the action of the nerve seems to exhaust itself, and hyperae- 
raia, geuerally, soon folio ws on anœmia.3 However, by reproducing, 
at short intervais, the irritation of the vaso-motor nerves, it is pos- 
sible to cause the ischeemic state to predominate for a certain time. 
Still I do not beheve that aïiy trophic lésion would be ever experi- 
mentally produced, by this method. Herr 0. Weber who, by means 
of an ingenious apparatus, says he lias kept up, for nearly a week, irri- 
tation of the cervical sympathetic nerve, of a permanent character, so 
to speak, and marked by a thermal decrease of 2° C, has not seen 
the slightest trace of nutritive trouble superveniug in the corre- 
sponding side of the face.'' Cases counected with human pathology 
yield the same testimony. Thus it is not rare to find, in certain 
cases of angioneuroses, amongst hysterical patients for example, 
a very intense and very persistent partial ischsemia; yet trophic 
troubles never show themselves, under such circumstances.^ As to 
the instances of spontaneous gangrené, which hâve been attributed 
to vascular spasm they would not hâve, to judge from my own 
observations, the signification assigned them ; for, in ail cases of this 
kind which I hâve happened to meet Avith, I hâve found the 

1 Brown-Séquard, 'Course of Lectures,' &c., p. 147, Philadelpliia. 
- Brown-Séquard, loc. cit., p. 142. 

^ Waller, 'Proc. Royal Society, London," Vol. ii, 1S60-72, p. 89 et seq. 
■» O. Weber, ' Centralblatt,' No. 10, 1864, p. 147. 

* Liégeois, 'Société de Biologie,' 1S59, p. 274. Charcot, iu 'Mouvement 
Médical,' Nos. 25, 26, ire série; No. i, nouvelle série, 1872. 



116 CONSECUTIVE TSCH^MIA. — DILATOR NERVES. 

calibre of the vessel occluded by an altération of tlie arterial walls 
•or obstructed by a tlirombus.^ 

From tlie foregoing observations you perceive that it is neither 
to a paralytic nor to an irritative affection of tlie vaso-motor nerves, 
properly so caîled, that we should attribute tlie tropliic disorders 
which supervene in conséquence of lésions of tlie nervous system. 

Physiological experiments. in thèse latter years, hâve revealed 
the existence of centrifugal nervous filaments, the irritation of which 
has the effect of determining dilatation of the blood-vessels, and 
consequently hypereemia of the région to which thèse nerves are 
distributed. 

Whilst irritation of the common vaso-motor nerves produces is- 
«hsemia, irritation of the dilator nerves détermines, on the contrary, 
a more or less intense hypersemia. The chorda tympani may be con- 
sidered, at the présent moment, as the prototype of dilator nerves- 
But nerves endowed with sitnilar properties exist in the face," in 
the penis,3 and in the abdomen.* There are probably others in 
-existence also in many parts of the body. 

"We are far from possessing a certain knowledge of the mode of 
action of thèse nerves. According to the hypothesis adopted by M. 
Claude Bernard, this is how we should explain the remarkable 
afflux of arterial blood which takes place in the submaxillary gland, 
under the influence of the chorda tympani. In the opinion of that 
eminent physiologist, the irritation of this nerve is transmitted to 
the little ganglionic masses which are distributed in great numbers 
on the intra-glandular extremities of the nerve. Thèse would, in 
their turn, react by a sort of nervous interférence'^ on the nerve- 
filaments of the great sympathetic or vaso-constrictor, and paralyse 
their action. Thus the chorda tympani, and the same doubtless 
should be said of ail the other dilator nerves, would play the part 
of a check nerve in relation to the vaso^motors. lience, as you 
see, the resuit of the action of the dilator nerves would, according 

' See the Tliesis of M. Beuni, 'Recherches sur quelques points de la 
gangrcuc spontanée,' Paris, 1867. Obs. v, xi, xvii. 

- Claude Bernard, 'Revue Scientifique,' t. ii, 2 série, 1872. Schill", 'Di- 
gestion,' t. i, p. 252. 

■* Ereetor nerves of Eckhardt, 'Beitragc zur Anat. uud Phys.,' t. ii. Luven, 
'Bericht der Sachs. Ges.,' 1866. 

■• Claude Bernard, loc. ci/. 

^ Claude Bernard, toc, ciL, p. 120^. 



DILATOR NEEVES. 117 

to this tlieory, be simply vaso-motor paralysis.' Now, if it he true 
tliat vaso-motor paralysis, even wheii carried very far, as happens 

' For a cliiiical illustration in the liuman subject of the pbysiological tlieory, 
see " Note sur la Paralysie vaso-motrice généralisée des membres supérieurs," 
parle Dr. Sigerson (Publications du ' Progrès Médical '), 1874, Adrien Delahaye, 
Paris ; or Translation by Dr. Bariiard Ellis, New York. 

The following are some of the principal featnres of this case, to which Dr. 
Duchenne (de Boulogne) invited the writer's attention, and which, at the 
request of that eminent physician, was made the subject of a detailed study, 
from pathological and physiological stand-points. Ths extract is taken from 
Dr. Barnard Ellis's translation : 

" History. — The patient C — , aged 50, a copper-trimmer by trade, is a man 
of robust cpustitution, and florid complexion, who bas hitherto enjoyed excel- 
lent health. He bas had neither cough, nor colic, nor any of the syniptoms 
usually assigued to copper-poisouiug, whether the heart, the respiratory, or the 
digestive organs, be considered. Tlie hands, which are in an abnormal condi- 
tion, présent no lésion except the cicatrix of an old whitlow on the left fore- 
finger. He came to be treated for impotence, and that, at first, was ail he 
complained of ; but other phenomena were soon discovered, some of which 
were traced back several years. By careful questioning the following facts 
were elicited. In 1872 he was aware of a weakness in the arnis and legs, but 
niost especially in the knees. This sensation, however, neither became localised 
uor remained constant ; it seemed to Ait through ail bis members. In 1873, 
he noticed that it predominated in the lefc kuee. This uneasy sensation, which 
gave no pain, and was transient, seemed to ascend along the leg from the calf 
to the thigh; and the proof that it was not mcrely a subjective sensation 
lies in the fact that the weakness of the leg increased so much at times that 
he was obliged to sit down. He usually recovered, however, in a few minutes, 
and was able to go about his work as before. No aggravation of his symptoms 
occurred when he walked out ; on the contrary, the exercise did him good, and 
after a brisk walk of half an hour he felt a marked sensation of pleasurable 
ease. 

This disorder, as we see, was intermittent, showing itself after intervais of 
comparative health. In January last (1874), however, he was attacked, in a 
more enduring manner, in both upper and lower extremities, — the feeling of 
debility being greatest in the left arm and right leg. So much was he enfeebled 
that, whereas when formerly attacked he could lift a weight of about two or 
three pounds, he became at this time unable even to keep his forearm flexed on 
his arm. He preserved the power of flexion, but not the power of maintaining it, 
as, in a few seconds, the forearm would fall of its own weight. At this stage, 
the niuscular force of the hands, tested by the dynamometer of Dr. Duchenne 
(de Boulogne) was équivalent, on an average, to 43 kilogrammes, or 94'6 Ibs. 

The colour of his hands had become a deep red, and this florid flusli ex- 
tended up the forearms, gradually diminishing in inteusity. Let us add that, 
notwitbstanding the vascular disturbauce, there was nothing that could be re- 
ferred to the existence of scleroderma, to which there was some superficial 



118 DILATOE NERVES. 

for instance in cases of complète section of the vaso-motor nerves, is 
not a cause of trophic disorders, the same rule must plainly hold 
good as regards the paralysis produced under the influence of the 
dilator nerves. But, gentlemen, as you will see farther on, the 
mode of action of the dilator nerves may be considered from an 
altogether difl'erent point of view. 

resemblance. The patient complained of great beat in tbe liands and fore- 
arms, and this increase of température was plainly perceptible to ail -wbo 
toiicbed tbeni ; and it is a very remarkable fact that tbeir sensibility was so 
sjrcatly augmentée!, that everytbing be toucbed — instruments, wood, or paper — 
appeared to bim as cold as ice. He was troubled with formication in tbe 
forearms, wbicb iucreased to a painful degree wben be rubbed*bis bands 
together as wben wasbing tbem. Heat aggravated and cold diminisbed tbe 
pain, — facts of wbicb be bad become aware on using cold and warm water. 

As to tbe inferior extremities, tbey preseuted différent pbenomena. Tbere was, 
indeed, debility, as bas been remarked, but tbe symptoms of tbe disease seem 
to bave dccussated. Whilst tbe left arm was tbe weaker, tbe riglit leg was 
tbe more fccble. Instead of tbe bypera?stbesia wbicb we observed in tbe 
bands, tbere was a notable loss of sensibility in tbe rigbt foot, so tbat be did 
not feel tbe ground wben walking. Tbis foot seemed to bim asleep or be- 
numbed. Tbere was, at times, sligbt formication in tbe rigbt leg, but very 
little in tbe left. Nor was tbere a bypotbermal condition bere, as in the upper 
extremities. Altbougb tbe température of tbe soles of bis feet seemed normal 
to bimself, duriug tbe daytime, it bad been remarked tbat, wben be was lying 
down and during tbe niglit, tbcy were ice-cold to tbe toucli. 

In tbe lunibar région, be bad experienced an intense itcbiness, as if be bad 
been beatcn witli ncttles. Tbis unpleasant sensation was not constant, and bad 
only appeared Cve or six times in ail, and tben only in tbe moruingand at nigbt, 
wben be was dressing or uudressing aud exposed to the cold air — pbenomena 
oceasionally présent in tbe case of persons suffering from urticaria. Tbere 
were no wbeals perceptible. It is bighly interesting to note tbat wben this 
■urtication niade its appearance in the loins, tbe formication disappcarcd from 
the upper extremities. 

As tbere was reason to suspect tbe existence of ocuhu- troubles, we iuterro- 
gated bis meniory and found tbat be bad observed somcthing like a mist before 
bis eyes, cspecially at uight. This disordor bad, iu fact, rcaehed such a point 
in January, 1874, tbat lie bad given up attenipting to read. On tlie left eye- 
ball, a barmlcss pterygium was remarked. Applying the opbthalmoscope, 
Profcssor Panas found that tbe fundus of tlie rigbt cye was normal, whilst 
tiierc was a very markcd excavation of the papilla of the left cye, tbe fundus 
of whieh was slightly congested. 

Let us note in conclusion, that during the conlinuancc of iiis ailinent be 
complained of great thirst, and of uiuiswal drowsiucss aftcr meals." 

This patient rccovcred under trcatment by faradisation, as relatcd in tbe 
trcatise already mcntioned (S.). 



SECEETOR NEEVES : LUDWIG S EESEAEOHES. 119 

I would remind you of tlie fundamental experiments of Ludwig, 
relative to tlie influence of certain nerves on tlie sécrétion of tlie sub- 
maxillary gland.^ Notwitlistanding tlie criticisms wliicli hâve assailed 
tlie conclusions drawn from his experiments by this celebrated phy- 
siologiste thèse conclusions do not appear to hâve been shaken. I 
hâve to request your permission to enter into some détails in ré- 
férence to this subject ; they are absolutely necessary for the object 
we hâve in view. 

When you irritate the peripheral end of the nerve proceeding to 
the submaxillary gland — a nerve supplied as we now know from the 
chorda tympani — the following phenomena are observed. A very 
abuiidant sécrétion of saliva is produced, — the quantity may be so 
large that, in a short space of time, the volume of saliva secreted 
shall greatly exceed the volume of the gland itself. This fact demon- 
strates at the outset that we hâve not to deal hère with a simple phe- 
nomenon of excrétion, or expulsion of previously secreted saliva. 

According to the views of Stilling and of Henle, which prevailed at 
the time Ludwig published his first investigations, one might be 
tempted to explain the phenomeuon in question by admitting that 
the irritated glandular nerve acts upon the veins of the gland, caus- 
ing tliem to contract. The augmentation of the tension of the blood, 
conséquent on the venous contraction, would, by this hypothesis, be 
the cause of the augmentation of the salivary sécrétion. But 
Ludwig lias shown that ligature of the veins, without concomitant 
irritation of the glandular nerve, does not increase the sécrétion of 
saliva. That second hypothesis should, therefore, also be eliminated. 

But perhaps the irritation of the glandular nerve Jwhich, as you 
are aware, lias the effect of inducing dilatation of the arteries may 
détermine the sécrétion, simply because it momentarily augments 
the afflux of arterial blood into the gland? This argument is 
reiidered invalid by an experiment, made by Ludwig, which shows 
that, during irritation, the manometric pressure in Wharton^s duct 
is superior to the pressure of the blood in the arterial conduits. 
Besides, the hypersécrétion of saliva from irritation of the chorda 
tympani is still exhibited, after ligature of the arteries supplying 
the gland — in the case of an animal killed by bleeding — or even in 

' Ludwig, 'Mitth. der Zuricli Naturforscli.,' 1851. ' Zeitsclir. fur rat. Med.,' 
n. f. Bd. i, p, 255. 'Wiener Med. Wochensclir./ 1860, x, No. 28, p. 483. 
See also the works published by Ludwig in co-operatiou with Bêcher, E,ahn, and 
Gianuzzi. 



120 LUDWICt's eesearohes. 

tlie case of a head separated from the body. Let us also add tliis 
most remarkable fact, namely, the saliva and the venous blood 
which flow forth from the submaxillary gland, whilst the glandular 
nerve is being stimulated, présent, as MM. Ludwig and Spiess^ hâve 
shown, a higher température than the arterial blood which passeS'^ 
into the gland." 

Judging from the gênerai bearing of thèse results, it appears évi- 
dent that the influence of the nervous System on the submaxillary 
sécrétion cannot be explained by the simple phenomena of vascular 
dilatation and constriction. We are induced to recognise in the 
glandular nerve a two-fold property, since, in addition to its 
influence over the vessels, the dilatation of which it détermines, 
it also exerts an immédiate action on those parts of the gland 
which accomplish the chemical act of sécrétion, or, in other 
words, upon the secreting cells. This influence of the nerve upon 
sécrétion seems, indeed, to be the fandamental fact, for it shows 
itself, in conséquence of excitation, even when the effects of the 
concomitant dilatation are annihilated. As, on the other hand, it 
does not appear possible, experimentally, to suppress separately 
the secretor action, leaving the dilator action alone persisting,^ it 
is legitimate to suppose that the latter dépends on the former as a 
more or less direct conséquence. 

We had, therefore, reason to inquire what might be the link 
of connection between the excitation of the secretor éléments deter- 
mined by stimulation of the nerve, and the hyperœmia which 
follows that excitation. Several physiologists hâve thought tliat 
we hâve hère to deal with an attraction which the secretor éléments 

1 Ludwig imd Spiess, ' Sitzungsber.,' d. v., Ak. Math. CL, 1857, Bd. xxv, p. 

584. 

- In référence to tins, see a Lecture of M. Vulpian, ' Revue des Cours 
Scientifiques,' 3rd année, 1865-1866, p. 741. 

^ By récent experiments, however, M. Ileidenhain seems to liave been able 
to demonstrate tliat, in tlie chorda tympani, différent uerve-fibrils are devoted 
to sécrétion and to circulation in tlie submaxillary gland. Hc states that iu 
dogs, placcd undcr the influence of woorari, after injection into the jugular 
veiu of a dose of atropine sufficient to completely paralyse the cardiac filaments 
of the pneumogastric, the stimulation of the chorda tympani no longer deter- 
mined the sliglitest sécrétion. Nevcrtheless, tliere was an accélération of tl!£ 
venous currcnt which did not notably differ from the accélération determined 
by irritation of the chorda, beforc poisoning. 'Archives de riiysiologie,' 4 
Juillet, 1872. 



THEOEY OF ATTKACTION. 121 

of the gland sliould exert upon the blood. "So tliat to tlie force 
hitherto known as assisting the return of the circulating bbod 
to the heart and which is terraed vis a tergo, we should add a 
new attractive force in corrélation with the intimate nutrition of 
the éléments, a force named by many authors vis a f route '^^ Is 
this a purely theoretical conception, unsupported by experiments,. 
and merely destined to cloak our ignorance ? By no means. The 
Works of H. Weber, Schuler, Lister, &c.,2 contain numerous expéri- 
mental facts calculated to render évident the attraction which the 
tissues can exercise, under certain conditions, over the circulating 
blood. I will cite two facts, of this sort, as examples, in which 
the phenomena may be studied apart from any intervention of the 
nervous System. I borrow them from a lecture on the Theory of 
Sécrétions, delivered in the jMuseum of Natural History, by 
Professer Vulpian.^ 

If you eut ail the nerves of a frog's limb and then determnie an 
excitation by placing a small drop of nitric acid on the skin of the 
web of its foot, a more or less intense hyperœmia will be produced 
in this point, at the end of a certain period. The second fact 
is conclusive. An &^g on the fourth day of incubation présents 
a very distinct vascularity of the umbilical membrane. At that 
period, there cannot be the slightest question of nervous influence. 
Now, if you place a small drop of nicotine on any point of 
tliis vascular area, there ensues around this point so great a 
congestion that almost ail the blood flows thither. In truth, this 
hypersemia, this stasis by irritation of the tissues, displays itself, at 
first glanée, with I know not what semblance of a metaphysical 
conception. But an effort bas long since been made to give an 
interprétation of this phenomenon on physico-chemical grounds. 
Thus, in 1844, Dr. Draper^ remarked that where a capillary tube 
contains two liquids, of différent natures, if one of them hâve a 
greater chemical affinity for the parietes of the tube than the other, 
motion ensues, and the liquid which has the greater affinity pushes 
the other before it. The arterial blood having a greater affinity for 
the tissues than the venous blood, saturated with the products of 

' Vulpian, 'Revue des Cours Scientifiques,' t. iii, p. 744. 
2 See O. Welier, ' Haudbucli der Chirurgerie,' t. i, p. m. 
^ Vulpian, toc. cit., p. 743. 

* Draper, " A Treatise ou the Forces which Produce," &c , New York, 1844^ 
Savory, 'British and Foreigu Review,' t. xvi, 1855, p. 19. 



122 IRRITATION 01^ GLAND-NERVES. 

disintegration, it should follow that tlie venous blood would be 
driven b^k. According to this hypothesis, it would suffice to 
quicken the cliemical process of nutrition, in order to increase the 
intensity of motion (or afflux), and lierein the action of the nerves 
may intervene. The ])henomena of stasis are capable of being 
explained in an analogous manner, by an appeal to the laws of 
osmosis (blood-stasis, by diffusion) ,i 

However it be, Avhatever may be the explanation of the phenomena, 
you perceive that the attraction which the tissues, under the influ- 
ence of certain agents, exercise upon the blood is a fact experimentally 
established, w-holly apart from any action of the nervous system. 
Now, in order to apply this datum to the case of the submaxillary 
gland, it suffices to admit that the glandular nerve, when subjected 
to excitation, induces a modification of the intimate nutrition of the 
secretor cells — and then, in conséquence of this change, vascular 
dilatation would take place. 

Anatomy seems, besides, to throw a new light upon the question 
by showing that the terminations of the glandular nerves penetrate 
into the secretor cells. ^ Herr Heidenhain has even endeavoured to 
demonstrate that a gland, of which the nerves hâve been subjected 
to a somewhat prolonged irritation, présents a histological constitu- 
tion differing in some respects from that of a gland in a state of 
repose. The old cells, termed mucous cells, appear in fact, after the 
irritation, to be replaced by young cells of récent formation.^ If the 
views of Herr Heidenhaiu be confirmed, we should attribute to the 
nerve a direct influence, so to speak, upon the development of gland- 
cells.* 

The hypothesis which has just been formulated in relation to 
secretor nerves, might apparently be extended to other nerves in 
which expérimental physiology has discerned the property of de- 

' O. Webcr, loc. cit. 

"- E. F. W. Plùgcr, " Das Nervengewebe der Speiclicldriise," in Stricker's 
Ilandbucli, t. i, p. 313. 

' Heidenhain, " Sludien der Pliysiologischen Instituts," 3e Breslau, 1868, 
and Stricker's Ilandbueli, loc. cit., p. 330. 

■* According to M. Jlanvier ('Traduction de Frcy,' p. 437), aiid M. Ewald 
(' Jaliresber.,' t. i, 1870-1871, p. 55), the rcsults obtaincd by Ilerr Heidenhaiu 
ought to be intcrpreted as follows : — Under the influence of tlie irritation of 
the gland-nerves, the cells called mucous cells simply lose the mucus they 
<;ontain and résume the appearance of pariétal gland-cclls. Thcre would cou- 
sequtiitly be no formation of new cells hère, as Heidenhaiu asserts. 



TROPHIC NEEVE THEOKY. 123 

termining the dilatation of vessels under tlie influence of stiinuli. 
Thèse nerves would act primarily on the inter-vascuhir éléments and 
quicken therein the movements of composition and décomposition. 
Vascular dilatation would follow, as a consécutive phenomenon. In 
support of this view, one may hère also invoke the teachiugs of 
anatomy which, in thèse latter days, lias, it is stated, succeeded in 
following, at least in the frog, the nerve-endings even into the 
nucleoli of the corpuscles of the cornea, aud of the conjunctival 
cells of the nictitatiug membrane.^ 

This interprétation was long since proposed byM.Brown-Séquard,^ 
and Professor Schiff seems to countenance it when he acknow- 
ledges that *' active dilatalion appears to be alien to the proper 
coats of the vessels aud to take place through the médium of the 
inter-vascular tissues/^'^ 

The incursion which we hâve made into the domain of physiology 
was undertaken with the intention of collecting, as we went, évi- 
dences which we can uow profitably apply. It is requisite, indeed, 
to fîx your attention for a while upon the trophic nerve tlieory, 
as it is called, which, in default of otlier hypothèses whose insuffl- 
ciency was admitted, has been sometimes recurred to in order to 
explain the production of nutritive lésions developed by an influence 
of the nervous System. Now, by this theory, at least as it has 
been formulated by Herr Samuel, the supposititious nerves would 
be, as it were, constructed after the model of the secretor nerves in 
this respect that, like them, they would exercise, in the normal 
state, a direct influence over the nutrition of the parts wliere it is 
supposed their ultimate terminations are distributed. Their physio- 
logical rôle would be, not to operate directly, but to quicken, 
throughout the tissues, those exchanges which constitute elenientary 
assimilation and disassimilation, just as the function of the secretor 
nerves is to set at work in the gland-cell an inhérent property, inde- 
feasibly connected with the phenomena of intimate nutrition. The 
autonomy of the anatomical éléments in accomplishing the nutritive 
acts istherefore not at ail overlooked; it is only proposed toconsider 

' SeeKûhne, in 'Gaz. Hebdom.,' t. ix, No. 15, 1862. Lipmaun, "Endiguug 
der Nerven im eigentlicben Gewebe uud im hiutereii Epithel der Honihaut des 
Frosclies," in Virchow's ' Arcliiv,' 38e Ed., p. 118, 1869. Eberth, in ' Archiv 
fur Mikros. Anat.,' Ed. iii. 

^ Brown-Séquard, 'Eesearcbes ou Epilepsy,' p. 70. 'Central Nervous 
System/ pp. 148, 172, 174. 

■* SchifF, ' Leçons sur la Digestion,' t. i, p. 256. 



124 THEOKY OF SAMUEL. 

the trophic nerves as forming, in their totality, a perfecting appli- 
ance peculiar to superior organisms. 

So much for the physiological aspect of the theory : — Now, as re- 
gards its apphcation to the interprétation ofpathologicalphenomena, 
it is easy to conceive that a fréquent resuit of morbid irritation 
set up in nerves^ endowed with such properties, would be to carry dis- 
turbance into the intimate nutrition of the innervated parts, and to 
provoke therein, occasion serving, the consécutive development ofthe 
inflammatory process. Suppression of the action of thèse nerves 
would, on the contrary, hâve no other efPect than that of lessening 
the intensity of the nutritive movement, and circîimscrihed atrophj/ 
is mentioned as an example of the trophic disorders which may thus 
supervene. 

Thèse are the gênerai features of the theory ; as to the détails, it 
was to be anticipated that an hypothesis created by the need of ex- 
plaining as yet but little known phenomena, insufficiently examined 
at the period of its publication, was destined to become speedily 
antiquated. That, in fact, is what has happened. It cannot be 
admitted to-day, that ail the trophic nerves hâve their central 
origin in the posterior spinal ganglia, or in the analogous ganglia of 
the cranial nerves; for the cases are numerous, as you hâve seen, 
where a lésion, situated in the central portion of the spinal cord 
or even in the encephalon, provokes the manifestation of trophic 
dérangements in the peripheral parts. Henceforth, also, we must 
take count of facts, unknown when Samuel's book appeared, which 
place beyond ail doubt the influence of lésions of the anterior 
nerve-cells on the development of différent kinds of myopathies. 

I hâve never shared in the disdain with which the theory, that 
has just been briefly described, was almost universally met. It has 
ever seemed to me that, in spite of its imperfections, it was worthy 
of being recommended to the attention of physicians because it ex- 
plains better, in my opinion, the phenomena which they are called 
ou to observe, in practice, than ail the other hypothèses pre- 
viously invoked. I am very far however, from wishing to ignore 
tlie objections allegcd against it. In the first place, the existence 
of trophic nerves is not, certainly, demonstrated aiiatomically ; it 
must be admitted, moreover, that most of the experiments made 
on animais by Herr Samuel, with the object of revealing their 
existence, hâve not been felicitous. Some, when repeated by other 
obscrvers, hâve not hitherto reproduced the stated rcsults ; others- 



CEITICAL EXAMIXATION. 125 

îiave had to be given up, as tainted witli numerous causes of error.^ 
But ail the arguments directed against this theory hâve not so inucli 
value as thèse. If^ for instance^ we were bouiid to condemn the 
hypothesis of trophic nerves, by the mère fact that it is useless in 
physiology, I vvould point out that the utility of the secretor uerves 
was only recognised, as an afterthought. We should, in like manner, 
be necessarily compelled to recognise the utility of trophic nerves, 
if experiments should at any time déclare in their favour. Again, it 
is difficult to believe that the part played by the secretor nerves is 
absolutely spécial, and wholly unexampled in the organism. With 
thèse nerves we can already compare the dilator nerves^ if it be 
true that they act according to the mechanism already indicated. 
We should place also beside them, following the récent observations 
of Herr Goltz, the nerves of absorption which, according to this 
physiologiste act upon the endothelial cells of the blood-vessels in 
the same way as the nerves of sécrétion act upon the glandular 
epithelium. On the whole, we do not see that any reason exists 
to decree, a priori, that the trophic nerves shall not, some day, 
be called to a place in this group.- 

However this be, before adopting a theory which cannot subsist 
without calling out a whole system of nerves whose existence is as 
yet problematical, it is necessary to make sure, by every means, that 
it is really impossible to explain the phenomena, the interprétation of 
which is required, by appealing to the properties of the différent 
nerves already known. We must take care not to infringe the axiom 
of Logic, Hmid miiltijolicanda entia ahsque necessitate. Now, the 
vaso-motor theory being eliminated, there yet undoubtedly remains 
much to be done from this point of view. 

There is one opinion, amongst others, which has not received atten- 
tion, so far as I know, and which perhaps deserves to be taken into 
considération. The numerous and décisive experiments which hâve 
been recently made on the connexions formed by uniting ends of di- 
vided nerves possessingdifferent functions,such as the hypoglossal and 
lingual uerves for example,^ hâve shown that excitations, produced on 
any point of a sensitive or motor nerve-fibre, are propagated at once 

' See Tobias, ' Vircliow's Arcbiv,' bd. xxiv, p. 579, aud O. Weber in 'Ceu- 
trablatt,' 1864, p. 145. 

- Goltz in ' Pfliiger's Archiv,' t. i, v, p. 53, aud ' Journal of Anatomy aud 
Physiology,' 2nd séries, May, 1872, p. 480. 

^ Vulpiau, ' Pliysiologie du Système Nerveux,' p. 290. 



126 CONCLUSIOXS. 

and simultaneonsly in ceiitripetal and centrifngal directions. From 
this, it is allowable to suppose tliat pathological irritations, developed 
on a sensitive nerve, either at its central origin or on some point of 
its course, reverberating in a centrifugal direction to the ultimate 
extremities of the nerve-filaments, i.e., to tlie papillee of the derm, or 
the substance of the rete mucosum,,i could there provoke inflammatory 
action, in certain cases. In this way \ve could couiprehend, for in- 
stance, the somewhat fréquent development of pemphigoid or bullar 
éruptions, and of zona, in conséquence of lésions atfecting the pos- 
terior fasciculi of the cord, or the sensitive spinal roots. With respect 
to the motor nerves, I do not see any serious reason to prevent us 
from admitting that pathological irritations, affecting the nerve-cells 
of the anterior cornua, would sometimes be transmitted to the mus- 
cular fasciculi, by means of the nerve-hlaments which, in the physio- 
logical state, transmit voluntary excitations. A certain number, at 
least, of the trophic disorders, consécutive on lésions of the nervous 
System, would perhaps find their explanation in this hypothesis, 
without its being necessary to hâve recourse to the trophic nerve 
theory. 

We hâve arrived, gentlemen, at the conclusion of this pathogenic 
discussion, and, as I allowed you to perceive from the beginning, the 
question in dispute still awaits its solution. I shall not regret, 
however, the course of explanation we hâve followed, if, by placing 
before your eyes the documentary évidences of the case, I hâve suc- 
ceeded in inspiring you with the désire of entering more deeply into 
an investigation which concerns, to such a suprême extent, the 
pathology of the whole nervous System. 



See Langerhans, ' Vircliow's Arcliiv/ Bd. 44, aud A. Biesadecki, Stricier's 

dhiioli n rtnn 



Handbucb, p. 595 



PART SECOND. 



PARALYSIS AGITAIS AIS^D DISSEMINATED 
SCLEROSIS. 



LECTURE V. 

ON PAIIALYSIS AGITANS. 

SuMMARY. — Of trem.or in général. lis variefies. Intermittent 
tremor. Continuous tremor. Injfnence qf sleep, rest, an& 
voluntary motion. Distinction established hy Van Swieten, 
Opinion qf M. Gubler. Tremor, accordiîig to Galen^ 
Parali/sis agitans, and disseminated, sclerosis, — independenf 
d/iseases. Parkinson's researches. French worJcs : MM. Sée, 
Trousseau, Charcot, and TuJpian. Paralysis agitans admitted 
to the right of domicile in classic treatises. 

Fundamental cliaracters of paralysis agitans. A disease of 
adtdt life. Ils symptoms. Modifications ohserved in the gait.. 
Tendency to propulsion and retropulsion. Invasion; its modes, 
sloîo or ahrapt. Period of stationary intensity. Ilead and 
iLech not afecied hy tremor. Altérations qf speech. Rigidity 
qf the muscles. Attitude of the hody and limbs. Déformation- 
of the hands and f cet. Deluy in the exécution of movements. 
Perversions of sensitnlity . Cramps ; gênerai sensation of 
tension and fatigue : need qf fréquent change of position. 
Habituai feeling of excessive heat. Température in paralysis^ 
agitans. Influence of the hind of convulsions — stafic or 
dynamic. 

Terminal period. Confinement to bed. Disorders of nutrition^ 
Enfeehlernent of the intellect. Sacral eschars. Terminal corn- 
plaints : they differ from tkose of disseminated sclerosis^ 
Duration of paralysis agitans. 

Necroscopical results. Inconstant lésions in paralysis agitans j 
fixed lésions in disseminated sclerosis. Lésions of'the P&a^ 
Varolii and of the medulla ohlongata [Parkinson, Oppolzer) . 
Pathological Physiology. 

Fiiology. External causes ; violent moral émotions ; influence f)f 

9 



130 OF TEEMOE IN GENEE AL. 

(lamp cola, toïieu mucJt jyyolovged ; irrilatiou of ceriain penpTie- 
ral nerves. Preclis2msing ccmses. Influence of âge. Paralj/sîs 
agitans appears at a more advanced period of life ilian dis- 
seminated sclerosis. Sex. Ilereditary prédisposition . In- 
fluence of face. 

Gentlemen, — Those amongst you, wlio, this morning, passed 
tlirough our wards, were probably surprised to find coUected tliere 
so great a number of female patients, in wliom tremor seems to 
constitute tlie paramount or at least the most striking symptom of 
tlie disease wliich they labour under. This gathering of patients, 
forming a genus apart, I purposely contrived. In tliat way, I 
desired to enable you to recognise, by means of a comparative 
study, certain shades of distinction and even marked différences 
which the examination of isolated cases does not allow you so 
readily to discern. 

At first glanée, you may bave thouglit the scène monotonous in 
eharacter. Indeed, to a superficial observer the phenomenon of 
tremor in ail thèse women must appear identical, or almost so : oue 
thing alone strikes the gazer's glance, as peculiarly noticeable, it is 
the diversity in position and intensity of the rhythmical oscillations 
of the limbs. But a more attentive inspection soon allowed you 
to distinguish, under this apparent uniformity, différent features 
which at first had completely escaped you. 

Thus, to mention merely the most m.anifest fact, you hâve been 
enabled to remark that some of our patients do not tremble except 
when executing a coôrdinated movement with a member, as in the act 
of raising a glass of water to the lips to drink, or again when they 
attempt to rise from their chairs in order to walk about. In the 
latter case, every part of the body may be shaken by energetic 
eonvulsive movements, rendcring it difficult and sometimes even 
impossible to stand upright or to walk along the floor. On the 
other hand, when they arc at rest and not affected by any strong 
émotion, thèse same womeii, whether seated or lying, présent the 
most natural attitudes; the différent parts of their bodies are no- 
wise agitated, and if you saw them only under such circumstances 
you would certainly not suspect the disease which has possession of 

them. 

In a second séries of cases, on the contrary, the tremor is con- 
tinuous, permanent; it agitâtes the members unceasingly, allowing 



VAEIETIES OF TREMOE. 131 

thein no peace, and if purposed movements exaggerate it at times, 
repose does not cause its disappearance. In reality, during waking 
liours, when the affection is intense, tliere is no truce for thèse 
patients. Whatever be the position they assume, whether they sit 
or lie down, they are always trembling. Sleep alone puts a 
temporary stop to the spasmodic agitation of their members ; but 
hardly hâve they awaked than the tremor makes its appearance 
anew and soon résumes its former intensity. 

Thus, if we take count merely of this primary distinction, 
founded on the influence of repose and of purposed movements 
over the production of tremor, it becomes already possible, as you 
perceive, to gather into two principal groups the patients whose 
cases occupy our attention. 

The first group would comprise those in wliom tremor is only 
shown when an intentional movement is mâde ; whilst the patients, 
in whom tremor is a constant symptom, or from whom it rarely 
départs, except during sleep, would coustitute the second group. 
It must be noted, however, that each of thèse groups, far from 
formiug a homogeneous whole, embraces numerous morbid species, 
of very différent natures, in spite of the analogy impressed upon 
them by the possession of this symptom in common. 

The distinction which I strive to make manifest to you is, in my 
opinion, of the higheat importance in the history of chronic 
diseases of the nervous system, accompanied by tremor. In our 
own days, it lias been almost universally misunderstood, and, if I 
mistake not, you will seek in vain for a trace of it in our classic 
authors. However, as M. Guéneau de Mussy lias justly pointed 
out in a récent clinical lecture,^ the physicians of the last 
century had taken it into considération, and perfectly understood 
its value. 

Van Swieteu, among others, expressly recognised the two kinds 
of tremor; nay more, he endeavoured to connect each of them 
witli a particular physiological condition. Allow me, hère, to 
invite your attention to the commentary on the 625th Aphorism, 
where you will find a physiological interprétation of the tremor-symp- 
tom that is far from being devoid of interest even for a modem reader. 

Thus, according to Van Swieten, the tremor which persists, 
during repose in bed, results from an irritation that afïects the 

' Mussy, ' Gazette des Hôpitaux,' 1868. 



133 VAEIETIES OF TREMOR. 

nervous centres in an intermittent and rhythmical manner. This 
would consequently be a convulsive phenomenon — tremor coactus. 

On the other hand, the tremor which is exclusively shown, during 
the exécution of voluntary moveraents, would dépend on a defect of 
stimulus, the resuit of an insufïiciency of the nervous fluid whose 
function it is to cause contraction of the muscles under the 
influence of the will. This, therefore, would be a paralytic tremor 
— tremor a dehïl'itate. 

An interprétation of the phenomena, which does not radically 
diverge from the foregoing, was published, a few years ago, by 
M. Gubler, one of the few modem authors who bave upheld the 
distinction between the two kinds of tremor.^ M. Gubler notes 
that, in certain cases, the tremor consists, not in a succession of 
contrary movements withdrawn from the influence of the will, but 
in alternate contractions and relaxations of the muscles in action, 
whether employed to alter the position of a limb, or of the whole 
body, or to préserve the natural attitude of the varions parts. 
Hère, the muscular contractions, instead of proceeding, as in the 
normal state, gradually, imperceptibly, and without shock, take 
place on the contrary by jerks, and as if by interrupted current, 
with intervais of rest. This pathological condition which, according 
to M. Gubler might be designated muscular astasis, stands distinctly 
apart from that condition in which tremor is not determined solely 
by the contractions required to maintain the corporeal attitude or in 
obédience to mental command, and taking place by jerks. In the 
second case, involuntary and purposeless contractions really exist, 
and are incessantly excited by an internai stimulus. 

The classification must, in truth, be a most natural one, for it 
dates from long before Van Swieten : Galen had established it. He 
also, in fact, distinguished two kinds of trembling : one, which he 
designated rpefxoç (tremor), is the paralytic shake ; the other, which 
he styled îraXjuoç (palpitation), is the clonic, spasmodic, convulsive 
agitation.* 

But the physiological aspect of the disease must not detain us 
any longer, for we could not think of entering, at this moment, into 
a discussion which would be prématuré. Let it suffice that we hâve 
put prominently forward thosc characters which can bc recognised 

' 'Archives Générales de Médecine,' r;e série, t. xv, 1860, p. 702. 
- G. V. Van Swieten, ' Commeutaria/ t. ii, p. 167. Paris, 1771. 



PARALYSIS AGITANS AND DISSEMINATED SCLEROSLS. 133 

by the simplest observation, irrespective of any theoretical pre- 
possession. It is because thèse hâve not been considered, that the 
two affections which are to form the object of our first chnical 
studies — -2mrahjsis agitans and cîisseminated sclerosis — hâve remained 
«ntil to-day, confouuded under the same rubric, although they are, 
in every respect, perfectly iudepeudent of each other. Both, indeed, 
reckon tremor amongst their most important symptoms ; but, in the 
first, the rhythmical oscillations of the limbs are nearly quite perma- 
nent, whilst iu the second they only supervene on the attempt to 
exécute intended movements. We hâve just pointed out a distinctive 
character which already enables us to lay down a broad line of 
démarcation betweeu the two affections. However, that is far, 
indeed, from being the only one which we hâve to set before you, as 
you will hereafter perceive. 

Parali/sis agltans which shall first engage our attention and of 
"wliich I hâve shown you several well-marked examples, was the 
first to be inscribed on nosological lists. Its history, however, does 
not reach far back. The first regular description given of it only 
dates from 1817; it is due to Dr. Parkinson, who published it in a 
little work entitled ' Essay on the Shaking Palsy.' From that 
period, paralysis agitans lias been often mentioned in England and 
in Germany ; but in France it remained almost unheard of until 
thèse latter years, for, if I mistake not, it was first described, in an 
explicit manner, by M. G. Sée in his memoir on Chorea, wliere it 
figures among the diseases that might be confounded with St. 
Vitus' Dance. 

In 1859, M. Trousseau in his Lectures on Chorea succinctly 
tabulated the principal characters of paralysis agitans. Three years 
later ]\I. Vulpian and I published a study on this subject in the 
■Gazette Ilefjdomadalre} We had but recently been appointed to 
La Salptêtrière. Desiring to inform ourselves fully as to the 
nature aud characters of this disease, which we were called to 
observe, on a large scale, we were struck by the insufliciency of 
the détails to be fouud in existing works. This led us to collect 
the tacts which lay under our observation, and, uniting thèse 
'with the accounts given by foreign authors, we traced a tolerably 
■^complete history of paralysis agitans, considering the period. 

From that date, this disease obtained the right of domicile in 

' 'Gazette Hebdomadaire,' 1861, pp. 765, 816, et 1862, p. 54. 



134 HISTORIOAL SKETCH. 

classic Works. In the second édition of his lectures, Trousseau 
dévotes a considérable space to its considération. It figures in the 
last édition of M. Grisolle's book, and in Reynolds' EncijclopecVm •} 
but in ail thèse descriptions, and our own does not at ail escape this 
reproach, there is complète confusion between paralysis agitaus and 
disseminated sclerosis. The line of démarcation between thèse two 
diseases was for the first time indicated by myself, if I mistake not, 
in the thesis of M. Ordenstein.^ It behoves us thereforeto establish 
a parallel between thèse two affections, by comparing them with 
eacli other in the threefold relations of symptoms, causes, and 
lésions; for that purpose, we shall refer to the afore-mentioned 
documents and to the numerons observations which we hâve col- 
lected in this hospital. It will be easy for you to discern in the 
patients whom I hâve gathered together in thèse wards, the cha- 
racters which I am about to insist on. 

FUNDAMENTAL ChARACïERS OF PaRALTSIS AGITANS. 

Paralysis agitans, separated from foreigu éléments, is, gentlemen, 
at présent a neurosis, in this sensé that it possesses no proper lésion. 
In the différent accounts that hâve beeu jjublished we see incon- 
gruous lésions mentioned ; some of thèse belong to disseminated 
sclerosis ; others, by their multiplicity and their variability, yield 
support to our opinion that, up to the présent time, paralysis 
agitans can lay no claim to any definite material lésion. 

It assails persons alreacly advanced in âge, tliose especially who 
hâve passed their fortieth or fifticth year. This limit, however, is 
not absolute, for M. Duchenne (de Boulogne) has told us of a case 
where the patient was a youth of sixteen. However it be, its 
natural place is amongst the diseases of the second period of hfe. 
But it would be going too far to consider it as being a senile disease. 

l'requently the causes remain unknown. However, of the etio- 
logical data two deserve to bc cited : i°, dump cold, such as that 

' J. Koyiiolds, 'A System of Medicine,' t. ii, p. 184; art. 'Paralysis 
Agitaus,' by W. 11. Sandcrs. 

■■* ' Sur la paralysie agitante et la sclérose en plaques géucralisce,' Thèse 
de Paris, 1868. Celui, liowever, had remarked that in two cases of multiple 
induration of the braiu and spiual cord, the tremor was only exhibited after 
movemeuts which the patient wished to make, but never in a state of repose, 
nor duriiig sleep, " Ein Beitrag zur Lehre der Paralysis agitans," in ' VVieucr 
Med. Wochenschr.,' Mai, 1860. 



SYMPTOMS OF PABALYSIS AGITA^'S. 135 

arising froui a prolongée! sojourn in a badly ventilated apartment, 
or in a low dark dwelling on tlie ground lioor, &c. ; 2° acute moral 
p,molions. Tlie latter cause appears to be tolerably common. One 
of tlie patients^ wliom you bave visited, was seized under tbe fol- 
lowing circumstances : Her husband^ one of tbe Garde Municipale^ 
lormed part of tbe troops wbo fouglit against tbe insurgents in 
]832. Having seeu ber busband^s borse return riderless to tbe 
larraeks, sbe received a great sbock, dreading some disaster. Tbat 
"very day sbe began to tremble, and tbe sbaking, wbicb at first was 
localised in tbe rigbt band, extending gradually, invaded eacb of 
tiie otber members in succession. I sball bave occasion to quote 
i.umerous examples of tbe same kind for your information. 

Tbe symptoms of paralysis agitans are not ail of tbe same value, 
Tbe most striking symptom consiste of a tremor, existing even wben 
tbe individual reposes, limited at first to one member, tben little by 
'ittle becoming generalised, wliilst respecting, bowever, tbe bead. 
I0 tbis pbenomenon is superadded sooner or later an apparent 
dminution of muscular strengtb. ïbe movements are slow and 
seem feeble, altbougb dynamometrical experiments prove tbat tbis 
diminution is not real. Tbis motor impotence appears to be 
die in part, as we sball see, to tbe rigidity wbicb prevails in tbe 
miscles. 

A singular symptom is tbat wbicb, frequently at an early, but 
usially at a late period, cornes to complicate tbe situation — tbe 
patient loses tbe faculty of preserving equilibrium wliilst walking. 
In some patients also we notice a tendency to propulsion or to 
re-ropulsion : witbout feeling any giddiness, tbe patient is, in tbe 
fiRt case, propelled forward, and, as it were, compelled to adopt a 
qtick pace ; tbe individual is unable, witbout extrême difficulty, to 
stop — being apparently forced to follow a flying centre of gravity. 

A pecubar attitude of tbe body and its members, a fixed look, and 
in.mobile features sbould also be enumerated among tbe more im- 
portant symptoms of tbis disease. 

Tbe marck of paralysis agitans is slow, and progressive. Its 
(hraiïon is long — sometimes it bas gone on for tbirty years. Tbe 
fatal terin supervenes eitber by tbe advance of âge, or because 
o: intercurrent diseases wbicb may be accidentai or occasioned by 
marasmus, confinement to bed, &c. In tbe first case, an acute 
disease, sucb as pneumonia, occurs : in tbe second, deatb takes 
jiace froin a sort of nervous exhaustion, nutrition dégénérâtes. 



Î36 SLOW I^^VASION. 

ihe patient cannot sleep, escliars are formed aud conclude the 
morbid scène. 

Such, gentlemen, are tlie more gênerai characters of paralysi? 
■agitans. But in order that you may the better compreliend their 
significance, it is proper to enter more deeply into a study of the 
symptoms and to show how they arise, increase, and are connected 
'is'ith the différent stages of the disease. To this end, and in order 
to give greater clearness to our description, we will establisa 
■several periods which we shall describe, in due order. 

Let us examine, in the first place, the manner of its invasioi. 
Expérience teaches that paralysis agitans sets in sometimes slowly 
and progressively ; sometimes, on the contrary, in an almost abrujl 
manner. 

A. Slow invasion. — In the immense majority of cases, the 
invasion is insidious, the disease first showing itself as slight ano 
benignant. The tremor is circumscribed to the foot, the hand, œ 
the thumb. This symptom, apparently of so trifiing a nature, lorg 
remains solitary. It présents, however, certain characters whi^h 
require to be recognised, and on which we shall lay stress. Is the 
hand attacked ? Its several segments are seen to oscillate o^er 
-each other, stirred by an almost pathognomonic motion. The patient 
■closes the fîngers on the thumb as though in the act of spinnTig 
wool ; at the same moment the wrist is bent by rapid jerks upon :he 
fore-arm, and the fore-arm on the arm. 

At this stage of the disease the tremor may be merely passng 
^nd transitory. It breaks out when least expected, the pati;nt 
€njoying complète repose of mind and body, and it frequently occirs 
without his being conscious of it. The act of walking (even wliere 
the up])er extremities are afFected), the act of grasping, liftiag, 
taking a pen, writing, any effort at ail of the will, may at this cpoch 
often suffice to suspend the tremor. Later on, it will be no longer 
;so. Moreover, as it augmeuts in intensity and })ersistence, :he 
tremor invades little by little, and not without observing certain 
rules in its progress, the parts which hâve hitherto remained souid. 
If, for instance, it first aftected the right hand, at the end of so:ne 
months or of some years, the turn of the right foot will cône; 
next the left hand, and after that the left foot will be, successivdy, 
assailed. 

DecusscUed invasion is more rare. I hâve, however, at least twice 
■seen the affection first seize the right upper extrcmity, and pass 



ABEUPT INVASION. 137 

iiext to the left lower extremity. It is mucli more common to see 
the tremor confîned for a long time to the members of one side of 
the body {hémiplégie t^pe), or to the two lower extremities [para- 
plégie type). The head is always nearly quite respected at every 
stage of the disease, eveu in the most intense cases ; and this is a 
character to which we shall, hereafter, give ])rominence, for the 
contrary is often observed in the cerebro-spinal form of disseminated 
sclerosis. 

I hâve to ask your utmost attention to a mode of progresnve 
invasion which, although exceptional, is not the less worthy of 
interest. The tremor is not absolutely the first symptom recorded. 
It may possibly be preceded sometiines by a very remarkable feeling 
of fatigue, sometimes by rheumatoid or neuralgic pains, which are 
occasionally most severe, occupying the member or the régions of 
the members which sliall soon be seized, but secondarily, by the 
convulsive agitation. I might quote several cases of this kind to 
you, and, in such circumstauces, it is not rare to find that some 
traumatic cause exists, such as a puncture, as Piomberg lias seen, or, 
as 1 hâve myself observed, a violent contusion of the member which 
was ultimately taken with pain and trembling. The paralysis agitans 
which sets in, aftcr this manner, behavcs itself, however, throughout 
its ulterior course in the ordinary way, and its progress is effected 
in accordance with the same laws. 

B. Abntpt invasion. — Wheu, in conséquence of a moral cause, a 
shock of terror for instance, tremor suddenly supervenes, it sometimes 
occupies one member only, sometimes it seizes on ail the members 
at once, from the very commencement. After persisting for a few 
days it may possibly improve or even vanish. But, later on, after 
a séries of alternate improveraents and exacerbations, it takes up 
its abode in a permanent manner. This, at least, is what we hâve 
seen very distinctly occurring in several cases. 

The duration of this initial phrase varies from about one to two 
■or three years, whatever may hâve been the manner of its invasion. 

C. Period of slaiionary intensifg. — When paralysis agitans has 
acquired its perfect development, the trembling, besides invading 
several members, becomes, at least in severe cases, almost incessant. 
Its intensity, however, is not the same at ail times. Différent 
circumstances, formerly without influence over it, now augment it. 
Moral émotions count amongst thèse, and the exercise of voluntary 
movements. In addition, we find a kind of crises — paroxysms 



138 STATIONAEY PEEIOD. 

occurring spoiitaneously, without appréciable cause. Ou tlie otlier 
handj natural sleep, and sleep induced by chloroform, always 
annihilate tlie couvulsive jerking^ for tlie time being. 

At tliis stage of the disease, especially, tlie peculiar characteristics 
of the tremor are displayed in ail tlieir fuluess; then also we 
occasionally find the rhythmical and involuntary oscillations of the 
différent parts of the hand recalling the appearance of certain co- 
ordinated movements. Thus, in some patients, the thumb moves over 
the fiugersj as when a pencil or paper-ball is rolled between them ; 
in others, the movements are more complicated and resemble what 
takes place in crumbling a pièce of bread. I hâve shown you some 
examples of this kind. Thèse are, if I do not mistake, peculiarities 
which belong specifically to the tremor of paralysis agitans ; I do 
not believe that tliey are to be found in any other species. They 
hâve beeu clearly recognised by M. Gubler {J,oc. cit.), who, having 
occupied the position of clinical clerk in La Salpêtrière, was enabled 
to study the disease on a large scale.^ 



3 ^o' 

Y\g. 7. — Spécimen of bandwritiug iu paralysis agitansJ 
The hands aud neck, we repeat, remain unaffected ; this is the 

' The tremor causes the handwritiug to exliibit characters which are some- 
what spécial. When the disease is comraenoinf^, the writiug at first gUnce 
seeins normal, but when examined with a magnifying glass iuequalities are 
perceived, some parts beiug thicker and heavier than others. Later ou, in the 
period of stationary intensity for instance, tlie changes are more marked and 
consequently plaiuer. The above spécimen, fig. 7, represents the writiiig of a 
patient whose case we studied at the Hôpital St. Louis, in 1869. The strokes 
forming the letters are very irregular and sinuous, whilst the irregularities and 
sinuositics are of a very limited width (Bourneville). 

On a carel'ul cxamination of this spécimen of writiug it will be perceived 
that the down-strokes are ail, with the exception of the Orst letter, niade with 
comparative flrmness and are, in fact, nearly normal — the huer up-strokes, on 
tlie contrary, are ail trcmulous in appearance, aud it is to the uusteadincss of 
thèse liiies that the peculiar character of the writing hère is priucipally due. 
IVom this I would infer, that the flcxors of the fingers were, at this stage of 
the disease, less alfected by tremor than the extcusors, aud that, amougst the 



PHYSIOGNOMY. 139 

ruie. Far frorn trembling, tlie muscles of tlie face are motionless, 
there is even a remarkable fixity of look, and the features présent 
a permanent expression of mounifulness^ sometimes of stolitlness or 
stupidity. The njstagmus wliich so frequently figures in the 
symptomatology of disseminated sclerosis, lias no existence in 
paralysis agitans. Nor are the muscles of the jaws affected by 
convulsive agitation. Nevertheless, it is not uncommon to find 
that the tougue, even when enclosed in the buccal cavity, is 
stirred by a well-marked tremor, which augments when the organ 
is protruded. Sometimes the lips adhère, as though firmly pressed 
together, so that the red portion is no longer visible, and the 
cutaneous surface seems puckered.i Tliere is no real difficulty of 
speech, but the utterance is slow, jerky, and short of phrase : the 
pronunciation of eacli word appears to cost a considérable effort of 

latter, the iiiterossei were probably the earliest affected. This inference will 
not be without iiiterest for those who remember the attentiou wbich Dr. 
Ducheuue (de Boulogne) gave to the conduct of thèse muscles in the varions 
paralytic and atrophie affections of the hand (Sigerson). 

^ AU thèse characteristics are found well marked in the case of tlie patient, 
Marie-Anne Perd. . ., -wlio is still uuder M. Charcot's care (Salle St. Alex- 
andre, No. 9). The bead, held in a somewbat fixed position, is slightly bent 
forward. ïhe features are, so to speak, without expression ; the brovF-wrinkles, 
similar on botli sides, are deeply marked ; the eyelids are less mobile than in the 
normal state, on account of a species of contraction in the supraciliary muscle 
which appears habituai and which deepens the brow-wrinkles. When the patient 
is recjucsted to close her eyes, she does so, without effort, she says ; but the 
upper lids are tlicn stirred by little convulsive movements whicli would rather 
lead one to suppose that it required a certain force to keep them closed. And, 
in fact, if they be kept in this position, the convulsive movements (a kind 
of rapid winkiug) augment in direct ratio with the continuance of the 
test, so that the occlusion ceases to be complète. The eyes look straight for- 
ward ; there is no nystagmus. When, in cxamining the sensitiveuess to light 
of the pupils, we attemptto open and close tiie eyelids, iualternation, a certain 
résistance is met with, in the latter case, which is due to the convulsive move- 
ments of the upper lids that tiic patient canuot control. The gaze is, in some 
sort, without expression. 

ïhe lips are drawn togetiier and somewhat pouting, as though a muscular 
contraction maintained theiu in apposition ; it follows that the uaso-iabial 
furrows arc shallow, like the jugo-mental. The upper lip is motionless, the 
under lip is moved by a very fine tremor at the labial commissures. The 
patient is obliged to make an effort in order to open her mouth ; she can oiily 
open it imperfectly, and cannot keep it oj)en for a few minutes. She appears 
to account for this customary and as it were permanent apposition of her lips, 
when she says, "Elles se collent ensemble mes lèvres" (Bourneville). 



140 MODIFICATION OF UTTEEANCE. 

tlie will. If the tremor of the body be intense it may liappeu that 
the utterance will be tremulous, broken, jolted out as it were like 
that of an inexperienced rider on horseback, when the animal is 
trotting. However^ in botli cases, we sbould only recognise in this 
a phenomenon of transmitted tremor.^ Finally, the patients seem 
to speak between their teeth. Déglutition is accomplished with 
ease, though perhaps slowly ; frequently in cases of somewhat old 
standing the saliva, accumulated in the mouth, is involuntarily 
allowed to escape. The respiratory muscles do not seem to share in 
the convulsive disorder of the extremities. We bave to remark, 
however, that some patients expérience an almost continuai feeling of 
oppression. 

We shall now point out a characteristic which, we believe, was 
overlooked by Parkinson as well as by most of his successors : we 
allude to the rigidilj/ to be found, at a certain stage of the disease, 
in the muscles of the extremities, of the body, and, for the most part, in 
those of the neck also. When this symptom déclares itself, the patients 
complain of cramps, followed by stiti'ness, which, at first transient, 
is afterwards more or less lasting, and is subject to exacerbations. 
Generally the flexor muscles are the first, as they are always the 
most inteusely, affected. When this muscular stiffness bas become 
permanent it causes the patients, in many cases, to assume a cha- 
racteristic attitude. Thus on account of the rigidity of the 
anterior muscles of the neck, the head, as Parkinson remarked, is 
greatly bent forward, and, as one might say, fixed in that position ; 
for the patient cannot, without much effort, raise it up, or turn it 
to the right or left. The body also is almost always slightly 
inclined forward, when the patient is standing.^ 

1 lu référence to utterance, we may quote a fiagnieiit of the record of tlie 
patient, Perd. . . . Utterance begau to grnw difficult, in tliis woman, two 
vears ago ; and during the hist year the dilEcuIty has considerabiy increascd. 
Wlicn the patient spealcs, her lips tremble, and the enunciation of the first 
syllables is laboriously accomplished ; lier utterance is tremulous especially at 
first, gradually, as she goes on speaking, the tremulousness grows less, and the 
-words are pronounced in a stronger voice. The patient seems to speak between 
ber teeth ; hcr lips scarcely separate, and the jaws are, as it were, adhèrent 
each to each. The tongue is stirred by a uniform and gênerai tremulousness, 
even when lying in the buccal cavity, and when it is protruded the motion 
au"ments. The patient asscrts that she cannot kcep it out long : " It cornes 
back, in spitc of me," she says. The mouth is oftcn fuU of saliva, and Perd. . . 
attributcs to this fact part of her dilliculty of utterance (B.). 

- Sec plate at the end of this volume. 



ATTITUDE or UPPER EXTREMITIES. 



14B 



The attitude of the upper extremities deserves to be noticed. 
The elbows are habitually held a little apart from the chest, the 
fore-arms being slightly flexed upon the arms ; the hands, flexed 
upon the fore-arms, rest upon the stomach.^ In the course of 
time, the hands, on account of the permanent rigidity of certain 
muscles, présent déformations which it is necessary to be acquainted 
with, as they hâve frequently rendered diagnosis difiîcult. 




Fig. 8. — Tlie writiug liand. Habituai attitude of the band at a somewbat 
advanced stage of paralysis agitaus. 

Commonly, the thumb and index are extended and apposed, as if 
to hold a pen ; the fingers, slightly inclined towards the palm, are 
ail deviated outwards to the ulnar side (fig. 8). 

The fingers, in many cases, alternately flexed and extended at 
their several articulations, présent a séries of inclinations whicK 




Fig. 9. — Digital déformation, simulating tbat of primitive cbronic articulât- 

rbeumatisra. 

have a deceptive resemblance to certain types of déformation 
observed in chronic progressive rheumatism (figs. g and lo). 

The distinction, however, is usually made with ease, if the ob- 
server be forewarned and on his guard. In cases of paralysis agitaus 

' See plate at tbe end of tbis volume, iu wbicb the patient Gav. . . is 
depicted ; ber case is described iu an appeudix. Tbe inclination forward, wbicb 
was very marked wbeu M. Ricbard made tbe sketcb, lias since become more 
decided. Moreover, sbe now exbibits a tendency to incline towards the rigbt 
side. Tbis latéral inclination is found to exist also in another of M. Cbarcot's 
patients, named Bau. . . 



142 ATTITUDE OP LOWEE EXTREMITIES. 

there is found, in fact, neither tlie articulai- tuméfaction and stiff- 
ness, nor tlie osseous deposits and cracking sounds observed in nodose 
rheumatism. 




jpje. lo. Digital déformation, simulating tliat of primitive chronic articular 

rheumatism. 

Witli respect to tlie lower extremities, the rigidity of the muscles 
is sometimes so intense as to suggest tlie existence of real para- 
plegia^ witli muscular contracture. In tlie case of the two female 
patients, to wliom I directed your attention in tlie wards, their lower 
limbs, as you hâve seen, are rigid in semi-flexion ; they can neither 
be flexed nor extended witliout considérable difficulty. The knees are 
drawn togetber in adduction : tbe feet are stiff, extended, and turned 
in, simulating tlie malformation known as talipes equinus {parus) club- 
foot; the toes are raised and recurved so as to form a griffe (or claw) 
on account of the extension of the first and concomitant flexion of 
the second phalanges. Nevertheless, thèse women still retain the 
power of moving their lower extremities, thougli slowly indeed and 
with difficulty : they are even able, as you hâve witnessed, to walk 
in a kind of a way, without assistance or support. I hâve pointed 
out to you, gentlemen, that, contrary to what takes place in true 
paraplegia with contracture, we do not hère discover that tétanie 
tremulation, which, whether arising spontaneously or provoked by 
certain attitudes, characterises one of the varieties of spinal cpilepsy. 
This symptom, on the other hand, is generally found in the para- 
plegia which frequently accompanies disseminated sclerosis, and this 
is a distinguishing character on which we shall hâve occasion to lay 
stress in diagnosis. 

As Herr Bencdikt has remarked in liis récent treatise on Electro- 
thcrapeutics, the habituai rigidity of a certain number of muscles 
undoubtedly contributcs, to a great extent, in rendering movement 
laborious. But this is not, we believe, the only cause that should 
bc recognised. ilowever, it is this rigidity which, detcrmining the 
«^••eneral attitude, is the reason that the patients, shrunken upon 



PAEALYSIS AGITANS WITHOUT TREMOE. 143 

theraselves as it were, seem to move ail of a pièce ; 1-liat tlieir joints 
ap23ear " soldered together/' to use a common but lairly descriptive 
terni whicli I borrow from a patient ; and that, finally, thc head 
and body are kept inclined forward~-a circumstance whicli bas 
certainly its own share in producing that tendency to fall forward 
"wbich the patients expérience when walking. 

Gentlemen, there are cases^ thougli thèse are rare indeed, in 
which muscular rigidity is a syniptom of the early stage of the 
disease, and a really prédominant one. I bave recently observed an 
example which belongs to this category. The patient had scarcely 
noticed the tremor which, in fact, showed little intensity in bis case, 
and was confined to one hand. He already displayed, however, in 
a high degree, the peculiar attitude of the body and its members, 
the difficulty of movement, and the characteristic gait.i Such 

' Tlie followiug case, wliicli we abridge, belongs to tliis category of excep- 
tional facts. Guill. . ., aged 53 years (Salle St. Alexandre, No. 10, La Sal- 
pêtricre) after haviug, for some time, suffered from ccplialalgia, wanderin"* 
pains of a laucinating character, and a feeling of constriction at the epigas- 
trium, noticed, four years ago, that the différent joints of the rigiit upper 
extreinity were growing stifl". To this phenomenon, weakness was superadded. 
The stifFness and debility invaded, successively, tlie leffc lower extrcmity, the 
left arm, and afterwards the right leg. In 1870, a tendency to propulsion and 
retropulsion made its appearance. Thus when the patient ascended tlie stairs 
to lier lodgiug, she was propelled forward, and only stopped when she could 
lay hold on some resisting body; "without this précaution," she said, "l'd 
upset." 

To-day, her condition is as follows : — Head slightly beut forward, ncck stifF. 
The brow is deeply furrowed, cspccially over the eyebrows, whicli are uplifted 
as are the upper eyelids : hence the physiognomy lias a sort of stolid look. 
Utterance is free. In walking, the patient takes short steps and kceps the 
arms close to the body, the fore-arms flexed, aud the hands joined together, as 
if for support. The fingers, takeu together, are slightly bent and gathcred ; 
the whole hand is inclined outward towards the ulnar side. Ail the joints 
are stifF, but in différent degrees, the stiffness being greatest on the right side. 
Sensation is preserved. During the night, the patient expériences a feeling of 
cold which passes down from the shoulder to the wrist, and returns in fits 
lasting from five to six minutes. The members, especially the right arm, feel 
heavy. When the patient wishes to rise from her chair, aud is hiudered 
from helping herself by grasping adjacent objects, she catches the legs of the 
chair with her hands in order to draw forward the pelvis, then she puts her 
hands lower down ou the sides of the chair, and after some efforts and a kind 
of balancing to aud fro, she succeeds in getting up. 

Her slumber is generally short. During the night, Guill. . . keeps herself 
covered with the slieet only, having a thin petticoat spread over her knees 



144 EXECUTIVE EETACDATION. 

cases are exceptional. Most commonly muscular stiffness only 
appears, or becomes prominent, in tlie aclvanced pliases of paralysis 
agitans. Now, when it begins to be nianifest the patients bave 
long experienced, in the exécution of movements, a notable want of 
ease which is due to anotber cause. 

You will readily discover, in some of the patients whom I bave 
sbown you, tbat laboriousness in tbe exécution of movements wbicli 
is dépendent neitber on tbe existence of tremors, nor on tbat of 
muscular rigidity ; and a somewbat attentive examination will enable 
vou to recognise tbe significant fact tbat, in sucb cases, tbere is 
rather retardatiou in the exécution of movements tlian real eiifeehle- 
ment of iîie motor pon-ers. Tbe patient is still able to acconiplish 
most of tbe motor acts, in spite of tbe trembling, but goes about 
performing tbem witb extrême slowness. We noticed tbis fact a hw 
moments ago, in its relation to tbe faculty of speecb ; tbere is a 
comparatively considérable lapse of time between tbe tbougbt and 
tbe act. One migbt suppose tbat tbe nervous influx cannot be set 
to work, in ber case, until after extraordinary efforts, and, in reality, 
tbe sligbtest movements occasion extrême fatigue. Tbis group of 
phenomena bas been frequently taken as an indication of a real para- 
lytic enfeeblement. Nevertbeless, you will bave many an opportunity 
of assuring yourselves tbat in cases wbere tbe disease bas not yet 

because tbey ave cold. A coverlet, she says, "wouldbetoo warm and too 
hcavy." Let us note also an incessant ueed of change of posture (or fidgetiuess). 
She is seavcely seated for four or five minutes wlien she asks to be placed farther 
forward, then to one side, &c. Some moments after, she requests tliat her 
legs (which hâve a tendency to adduction) shall beseparated ; then she begs to 
1)0 lieljied to rise. AU thèse symptoms sufBce to show that we hâve hère a 
case of paralysis agitans. Ncvertheless, although the disease is of four years' 
standing, there is scarcely auy trembling, the right hand alone being afiected 
by it, and that only for the last three mouths. From this it will be seen that 
it is possible to diaguose paralysis agitans, even when tremor is absent (B.).. 
It was the same witli respect to another patient whom M. Charcot observed, 
a short time ago (1872). This man, aged 50 years, was attackcd by "Parkin- 
sou's disease" in conséquence of a strong émotion oeeasioued by the attcmpts 
of the Federalists, during the time of the Commune, to incorporatc him ia 
their battalions. In his case, ail tiie symptoms and cspccially the attitude 
were présent, but tlic tremor was likewisc déficient. Fiiiully, ]\lr. Goweis has 
coiniiiunicated to M. Charcot a case, noted by him, in the National Hospital 
for Epilepsy and Paralysis of London ; the patient, a woman uamed Anne 
Phillij)S, cxhibited ail the symptoms of paralysis agitans, cxccpting the trem- 
bling, wiiich is barely perceptible in her movements. (B.) {Noie to the second' 
dit ion.) 



MUSCULA.U STRENGTH. PECULIAR GAIT. 145 

reached its last limits, the muscular power is retained, in a remarkable 
degree. This fact bas been verified, on several occasions^ by means of 
the dynamometer : in some cases, even, the curious pheuomenon was 
noted of the greatest amount of measured force being présent in 
that member which was to ail appearance the weakest and most 
tremulous.^ 

Yet a Word upon the gaït peculiar to patients affected by 
paralysis agitans. You bave seen some of our patients get up 
slowly and laboriously from their seats_, hesitate for some seconds 
to step ont, then, once started, go off in spite of themselves at a rapid 
rate. Several times they threatened to fall heavily forward. Does this-- 
irrésistible tendency to adopt a running pace dépend exclusively on 
the centre of gravity being displaced forward by the inclination of 
the head and body ? This explanation, which may, perhaps, be 
admissible in some instances, will not serve for ail. There are, in 
fact, certain patients who, in contradistinction to those described, 
tend to run backwards when in motion, and to fall backwards,. 
although their bodies are manifestly inclined forward. Besides,, 
propulsion, like retropulsion, is not absolutely connected with the' 
bent attitude of the body, for it is sometimes seen at an early 

^ We bave examined tlie amount of dynamornetrical force présent, in six 
of M. Charcot's patients. The followiug are the results : 

ist. Perd. — Eight explorations : average on tlie right side, 60 ; ou the left, 

42. 

2nd. Guill. — Nine explorations : average on the right side, 67 ; on the leffc, 

3rd. Berr. — Tliirteen explorations : average on the right side, '^ffd ; on the 
left, 41 "4. 

4th. Gav. — Five explorations: average ou the right side, 39"6 ; on tlie lel't, 

43"4- 

5th. Beau. — Five explorations : average on the right side, 65\rj ; on the 
left, 4 2 '3. 

6th. Dan. — Five explorations: average on the right side, 41 "4; on the left 

33'3- 

If thèse figures be compared with the standard average 85, which we 
obtaiued by similar explorations in the case of five persous of the same âge 
as our patients, it becomes évident that the dynamornetrical force, far froni 
being preserved in paralysis agitans, is, on the contrary, dimiuished. It is ail 
the more difficult to explain the divergence betweeu the old opinion and our 
facts, since in two of our patients this diminution is as well-marked at the 
early stage of the disease as at the most advanced. Finally, in three cases, 
the dyuamometrical enfeeblement is greatest on the side where tremor pré- 
dominâtes (B.). 

10 



146 PROPULSION AND EETROPULSION. 

period of the disease, even before there is any inclination of tlie 
body at all.^ In short, thèse are not constant and necessary phe- 
nomena; they are even frequently enough absent, and are to be 
found in the symptomatic tables of diseases other than paralysis 
agitans, as in certain cases of cérébral lésion, for example, It is, 
however, right to mention that, in the latter event, they are often 
connected with vertigo, whilst in paralysis agitans the movements of 
propulsion and retropulsion do not supervene in conséquence of 
any feeling of giddiness. 

The symptoms which I hâve just reviewed are not, gentlemen, the 

^ Thèse phenomena are very évident in a patient under M. Charcot's charge 
(Salle St. Alexandre, No. 22). This woman has attained a more advaneed 
stage of the disease, without however beiug bed-ridden, than the two patients 
mentioned in the preceding notes. Ail the symptoms of the disease are met 
with in her case ; but we shall merely sélect from her history the tacts which 
relate to propulsion and retropulsion. Suppose, when seated, shc is direcied 
to arise and walk, what do we observe ? She hésitâtes for a few moments, 
then bends the body forward, aud after swinging herself to and fro, as it were, 
suddenly rises. When up, she does not set o£f at once ; she seems to require 
to poise or balance herself first ; she appears in some sort uncertain, the body 
being iuclined forward ; finally, she décides to start. Slow at the outset, her 
gait is gradually accelerated, and, after a course of teu yards, she rushes forward 
at such a rate that if, at a given moment, she did not fîud some obstacle to 
lay hold on — a bed, chair, or wall — she would fall suddenly. In this case, 
thercfore, iwopulsion is as manifest as possible. 

Retropulsion is sometimes overlooked because, in order that patients should 
be conscious of possessing it, they nnist hâve had some spécial occasion to 
walk backwards. M. Charcot employs a very simple method of exhibiting its 
existence. When the patient is standing, it sufBces to pull her, unexpectedly 
and slightly, by the skirt, in order to make her immediately commence 
walking backward ; the rétrograde movement soon becomes very rapid, and 
would be quickly dangerous if proper précautions were not taken (B.). 

The fact of the phenomena of propulsion and retropulsion bciug both 
présent in the same patient furnislies an argument in support of Professor 
Charcot's proposition that the propulsive tendency is not absolutcly connected 
with the forward attitude. In this case, the woman when stopped in the 
midst of an onward walk, being caught by the gown and gently pulled back, 
immediately began to recède, aud this without any perceptible change of 
attitude. As mention has been made of the existence of a stolid look, in 
such patients, it will not be uniuteresting to note, in relation to the question 
of the influence of disease on tlic mental faculties, that although this patient 
was in an advaneed stage of the discase and had the charactcristic facial signs, 
her niind appeared stiil active (in 1874). "Elle va comme une machine," 
said au observer, on seeiug lier walk. " Mais oui, comme une maciiine ù vapeur," 
was her quick rcsponse (Sigerson). 



DISAGREEABLE SENSATIONS. 147 

only phenomena wliicli deserve to arrest your attention. Paralysis 
agitans is not merely one of the saddest of diseases, inasmuch as it 
deprives tlie patients of the use of tiieir limbs, and sooner or later 
reduces tliem to ahnost absolute inaction ; it is also a cruel affection, 
because of the unpleasant sensations which the sufîerers expérience. 
Usually, indeed, (the neuralgic cases which we hâve already described 
being excepted), they are not affected by acute pains, but by dis- 
agreable sensations of a spécial order. They coniplain of cramps, 
or rather of a nearly permanent sensation of tension and traction in 
most of the muscles, There is also a feeling of utter prostration, of 
fatigue, which comes on especially after the fits of trembling ; in 
short, an indefinable uneasiness, which shows itself in a perpétuai 
désire for change of posture. Seated, the patients every moment 
feel obhged to get up ; standing, after a few steps they require to 
sit down. This need of change of position is principally exhibited 
at night in bed by the more infirm, who are incapable of attending 
on thcmselves. The nurses charged witli their care will tell you : 
" They must be turned now on the right side, now on the left, now 
on the back." Half an hour, a quarter of an hour, has scarcely 
elapsed until they require to be turned again, and if their wish be not 
immediately gratified they give vent to moans, which sufhciently 
testify to the intense uneasiness they expérience. In spite of 
thèse différent troubles, the transmission of the cutaneous sensitive 
impressions is not altered in paralysis agitans ; cold, beat, a pinch, 
the slightest touch, are ail jierceived, as in the normal state, and 
with the wonted rapidity. 

But there is one very troublesome sensation which the patients 
expérience, and which I hâve not found mentioned in auy description ; 
this is an liabïtual sensation of excessive heaf, so tliat you shall see 
them in the heart of winter throw oflp the bedclothes, and in the day- 
tinie only retain the lightest garments. Ail the cases under our 
charge give évidence in favour of this assertion. It is a peculiarity 
worth noticing, although no reason can be given for it, that this 
sensation of beat is especially felt in the epigastrium and the back. 
Still it may affect the limbs and face also. It is not of uniform 
intensity at ail times. It appears to attain its maximum after the 
paroxysms of trembling, and it is then frequently accompanied by 
profuse pcrspiration, which is sometimes so great as to necessitate a 
change of linen ; but it may also be found in patients who do not 
thus perspire and who are but little troubled with tremor. 



148 SENSATION OF HEAT. TEMPEEATURE. 

The knowledge of tliis fact long since led me to inquire whetlier 
the central température Avas altered in thèse patients. Now expé- 
rience has proved to me that, whatever may hâve been the intensity 
of this subjective sensation or of the tremor, the (rectal) température 
remained at the physiological limit (37'5° C. = 99"5° 3^.)- 

You will not be surprised, gentlemen, to lind that the muscular con- 
tractions, even when so energetic and gênerai as are those we note 
in certain cases of paralysis agitans, do not give rise to an accumula- 
tion of heat in the central parts. Thèse muscular contractions are 
dynamïc. Now, you are aware that siat'ic muscular contractions 
alone, as M. Béclard has pointed eut, occasion an élévation of tem- 
pérature thermometrically appréciable. Prom this point of view, as 
we, M. Ch. Bouchard and myself, hâve endeavoured to estabhsh, in 
an essay communicated to the Société de Biologie/ convulsions may 
be classed under two heads : 

1°. Siatic, in which tonic contractions predominate; thèse 
augment the température to a more or less marked extent. To this 
category tetanus and epilepsy belong. 

2°. Dynamic, in which clonic convulsions predominate. Thèse 
do not affect the température in a marked manner. Thermometrical 
explorations, which we hâve repeated many times in cases of paraly- 
sis agitans, and in some cases of chorea characterised by excessive 
agitation, seem to us to hâve placed the latter point beyond ail doubt.^ 

In connection with this question it would be interesting to déter- 
mine whetlier the urine, in paralysis agitans, présents any important 
modification in its chemical composition, and, particularly, any aug- 
mentation in the proportion of sulphates, inasmuch as, accordingto 
Dr. Bence Jones, such changes take place in chorea and delirium 
tremens — diseases in which there is great muscular expenditure. 

1 " Sur les variations de la température centrale qui s'observent dans 
certaines affections convulsives et sur la distinction qui doit être établie u ce 
point de vue entre les convulsions toniques et les convulsions cloniques." — 
'Mémoires de la Société de Biologie,' i866. 

" This statement is corroborated by fîve new cases. Tive explorations 
niade in the case of Bcr. gave an average température of 37*48° C. In the 
case of Guill, tliree explorations gave 37"6°. In the case of Dan. thrce morning 
explorations gave 37*3° C. ; and four evening explorations, 37.8°. In the 
case of Grav. two morning explorations gave 37°' ; and four evening ex- 
plorations 37'6". In the case of Bau. thrce morning explorations gave 37'i° ; 
and four evening explorations 37'45°. The puise in tlic first case rcached 90; 
ia the second, 86; in the third, 84; and in the liftli, So. The uumbcr of 
respirations, in thèse cases, was normal (B.). 



TEKMINAL PEEIOD. 149 

Tliis is a desideratum which we propose some day to make 
good.^ 

Gentlemen, tlie symptoms we liave described to you persist, such 
as we see tliem, for a less or greater lapse of time ; tlien, sooner or 
îater, there cornes a period that heralds the fatal issue, which may be 
•called the terminal period. The affection pursuing its course, the 
difficulty of movement increases, and the patients are obliged to 
remain, the whole day long, seated ou a chair, or are altogether con- 
fined to the bed. Then, nutrition suffers, especially the nutrition of 
the muscular System. There may supervene, as I hâve twice observed, 
a genuine fatty wasting of the muscles. At a given moment, 
the mind becomes clouded and memory is lost. General prostration 
sets in, the urine and faîces are passed unconsciously, and eschars 
appear upon the sacrum. In such cases, the patients succumb 
to the mère progress of their disease, by a sort of exhaustion of 
the nervous system; and it is perfectly true, as several authors 
hâve remarked, that at this terminal period the tremor, however 
intense it was before, is frequently seen to diminish and even to 
disappear.2 On a post-mortem examination, it is not common to 
£nd any important viscéral lésion capable of accounting for the 
occurrence of death. We do not observe, for instance, the lésions 
of caseous pneumonia, or of tubercular phthisis, which, as we 
shall see, usually terminate the existence of women attacked with 
disseminated sclerosis or with progressive locomotor ataxia. 

Such, however, is probably not the most usual kind of death in 

' Researches hâve since beea made, iu référence to tliis subject, by M. P. 
Eegnard iii the laboratory of the Sorbonne, — two of the patients in M. 

' Charcot's wards beiug placed under examination. In both cases, the urine 
contained a nearly normal proportion of urea, but a less than normal propor- 
tion of sulphuric acid. The average of fourteen spécimens gave 19*50 
grammes of tirea ; and i'25 instead of 2 grammes of sulphuric acid. 
It follows from thèse analyses that the excrétion of sulphates is 
diminished in paralysis agitans, contrary to the opinion advanced by Dr. 
Bence Jones when treating of chorea. In the latter affection, indeed, 
Lehmann and Gruner hâve always found a diminution of sulphates. Vogel, 
on liis side, arrives at the same results, and he thinks that the contrary con- 
clusions of Dr. Bence Jones must be attributed to tlie insufficiency of the 
analytic method employed. — -Note to Second (FrencJi) Edition. 

- In the case of a patient under M. Charcot's charge (Latouil — Marie- 
Françoise) whose clinical history is given, i/i extenso, in the thesis of 

■Gîaveleira, the trembling completely disappeared the second day hIj:i 
^eath ('De la Paralysie Agitans,' 1872, p. 35). 



150 PATHOLOGICAL ANATOMT. 

paralysis agitaus. The fatal termination, in fact, is frequently owing 
to an intercurrent discase. Trousseau tlirice beheld death super- 
vene in conséquence of pneumonia, and I hâve noticed the same 
thing myself in several individuals suffering from paralysis agitans. 
Was this complication due to the habit whicli such patients hâve of 
remaining uncovered, even in the coldest vreather, on account of 
the sensation of interior heat they expérience ? We are unable to 
afhrm it. 

Let us not forget, gentlemen, that paralysis agitans is one of the 
grave affections of the nervous system whose duration is the longest. 
It may last for thirty years. The symptoms of the third period 
may themselves, as I hâve witnessed, linger on for four or five 
years. 

If I hâve dwelt thus minutely upon the symptomatological descrip- 
tion of paralysis agitans, it is because it constitutes, even at the 
présent hour, uearly the whole of the history of this disease. 

The few autopsies wliich hâve until now been made on persons 
supposedly affected by paralysis agitans may be grouped into three 
classes. 

The first class includes the cases in whicli no perceptible lésion 
has been met with in spite of the most attentive explorations. 
Several facts of this kind hâve been placed on record by différent 
authors. For my part, I hâve iioted three well-raarked cases 
of paralysis agitans in which the results of the autopsies were 
altogether négative. At other times, we find mention made of 
common-place lésions, particularly of senile cérébral atrophy ; now 
this may exist, as is well known, without the slightest tremor having 
been ever présent. 

The second class comprises the observations published by some 
authors, — Bamberger, Lebert, and Skoda, for instance, — under the 
head of paralysis agitans, and in which lésions hâve been found that, 
in ail probability, pertain to disseminated sclerosis. Such are the cases 
of Bamberger, Lebert, and Skoda. Was paralysis agitans really the 
disease under considération, or were not the clinical symptoms rather 
those of disseminated sclerosis ? The latter was certainly the fact, 
at least as regards Skoda's case. We shall, however, revert to this 
question, on a future occasion. 

Fiiially, the last group contains the case given by Parkinson and 
that of Oppolzer. In Parkinson's case, which, by the way, he 
relates at secondhand, it appears that there was an augmenta- 



PATHOLOGICAL PHYSIOLOGY. 151 

tion of volume, with induration of the pons Varolii, of the metlnlla 
oblongata, and of the cervical portion of the cord, and that in addition 
to this the nerves of the tongue and those of the arm were apparently 
tendinous. The latter necrosco])icnl détail, with others unnecessary 
to mention, seems of a kiud to throw doubt upon the value of this 
case from an anatomo-pathological point of view. 

As to the account given by Professor Oppolzer it is scarcely more 
conclusive, in our opinion, in spite of the importance that has been 
accorded it. On iwst-morteni examination there was also found au 
induration of the pons Yarolii, which, after microscopical scrutiny, 
was attributed to a hyperplasia — a prolifération of the connective 
tissue. What are the characters of this hyperplasia ? The narrative 
is silent respecting them. There is no mention, in the original text, 
of any atrophy of the nervous cléments, nor of any signs of fatty 
degeneration, two lésions given, for what reason I know not, in the 
version adopted by Trousseau in his clinical lectures. 

The foregoing considérations show, gentlemen, that the spécial 
lésion of paralysis agitans remains to be discovered.^ 

The pathological physïology of the disease is scarcely more ad- 
vanced tlian its anatomy. Very shortly, I expect I shall hâve an 
opportunity of demonstrating the accuracy of this assertion before 
you. I shall not dwell upon the subject now, as I désire to conclude 
the clinical history of paralysis agitans by stating what we know with 
respect to the etiology and therapeutical history of this disease. 

Etiology. — A. Among external causes, two especially hâve a right 
to be mentioned, in a tolerably large number of cases. Pirst 
in order comes the influence of violent shocks of the i nervous 
System — fright, terror, the sudden communication of bad news, &c. 
Instances of this kind abound in books, and the facts which wehave 

1 Since tbis lecture was delivered (iu 1868), M. Charcot lias bad occasion 
to make tbree new post-mortem exaniinations. Tbe lésions he met with are of 
two kinds : Those of tbe first, constant in thèse tbree cases, cousisted in (a) 
oblitération of tbe central canal of the spinal cord by prolifération of the 
epitbelial cléments wbich line the ependyma ; {b) prolifération of tbe nuclei 
which surround the ependyma ; {c) pigmentation of nerve-cells, most marked 
in Clarke's columu cliiefly. Of tbe second kind of lésion, one was peculiar to two 
of thèse tbree cases, and consistcd in a multiplication of tbe amyloid cor- 
puscles, — one was found only iu a single' case ; this was a sclerosed patch ou 
the posterior surface of the bulbus racbidicus. In tbe most marked case"(of 
paralysis agitans) there was no lésion of tbe protubentia or of the bulbus 
discovered. (For further détails, see Joffroy, ' Société de Biologie/ 1871.) 



152 EXTERNAL CAUSES. 

ourselves collected oblige us to put away ail scepticism on this 
subject. 

Of the female patients wliom we bave interrogated many related 
liow their complaint took its rise in the midst of the political com- 
motions by which our country has been agitated. It may be sufficient 
to mention the case of the gendarmées wife, which we bave already 
referred to, and that of a woman at présent occupying bed No. 3 in 
the Salle St. Alexandre, who began to tremble after a violent émotion 
occasioned by the events of December, 1851. Besides the instances 
which came under our own observation we may mention — 1°, a case of 
M. Hillairet (recorded in our memoir) concerning a father who saw his 
son killed before his eyes ; i°, another case, published by Oppolzer, 
relating to a burgher of Vienna, terrified by the bursting of a bomb 
beside liim -^ and 3°, a case given by Van Swieten, where a man 
was suddenly roused from sleep by a fearful thunder-clap. It would 
be easy to multiply examples, but this could add nothing to what 
we hâve already told you. What it behoves you to know is the 
fact that, in ail thèse patients, the trembling followed immediately, 
or almost immediately, on the occurrence of the cause. But the 
peculiar nature of the cause, be it known to you, does not impress 
any spécial character upon the disease. 

Let us note, in the second place, the influence of prolongea 
exposure to moist cold in the production of paralysis agitans, an 
influence which, according to some authors, should suffice to esta- 
blish its rheumatic origin. However, one important fact may be 
alleged against this view, which is that, neither before the develop- 
ment nor during the course of the disease, do we meet with any form 
of chronic or acute articular rheumatism, some rare cases excepted. 
We notice, at most, in cases where the influence of cold can be 
accused, the présence of wandering rheumatic or neuralgic pains. 

' In a work published in 1873 ('Berliner Klin. Wochenschrift,' No. 24, p. 
278, &c.), Dr. O. Kohts reports a number of cases of nervous affections, 
observed at Strasbourg, which the patients attributed to the terror caused by 
the bombardment of that city. The author, who expatiates complacently on 
that disastrous event, informs us that the number of bombs showered upon 
Strasbourg amounted in thirty-one days to 193,722, making, as he calculâtes, 
€249 V^^ day, 269 per hour, or from four to five per minute. Amongst the 
pathological cases quoted, three appear to relate to paralysis agitans : one is that 
of a woman, aged fifty years, another that of a woman aged sixty-one years, 
and tlie third that of a man aged fifty-six years. (B.) — Note to the Second 
French Edition. 



INFLUENCE OP COLD AND NERVE-IREITATION. 153 

In this conuectiou we may quote tlie case of a womaii to wliom 
your attention was drawn, and vvhose (elephantine) gait recalls that 
of tlie larger })achyderms. This woman, who was engaged in wafer- 
making, lived for over teu years in a very damp apartment on the 
ground-floor, and the description she gives of her unhealthy abode 
leaves no doubt upon the subject. She was, moreover, exposed to 
fréquent chills in carrying on her trade. 

There are cases in which this cause is, in our opinion, far from 
having played the part assigned to it. Such is that recorded by 
Eomberg relating to a man who, in 1813, was stripped naked by 
the Cossacks in snowy weather. Is the action of cold to be accused 
in this case, or the influence of terror ? 

Finally, we will point ont a third cause, which has been silently 
passed over, by most médical writers, in describing this disease, 
namely, the irritation of certain peripheral nerves, supervening in 
conséquence of a wound or contusion. A case mentioned by Haas, 
from Door, in 1853, and quoted by Dr. Sanders, appears to belong 
to this etiological group. It rehites to a girl of nineteen, under 
whose right toe-nail a thorn had penetrated. She immediately com- 
plained of acute pain, and soon after was seized with trembling, 
which, though at first limited to the wounded foot, gradually became 
generaHsed. This trembling, it is said, completely disappeared in 
the course of time. A termination so exceptional affords us reason 
to doubt whether this was really a case of paralysis agitans. 

The wife of one of our provincial brethren, whom I attended, 
received a severe contusion of the left thigh, owing to a fall from 
her carriage. After some time there supervened in the injured limb 
acute pain following the course of the ischiatic nerve, and, shortly 
afterwards, the extremity was affected by trembling throughout its 
entire extent. This tremor, which was at first temporary, became 
permanent later on, and finally invaded the other members. 

With this case we may place that of a midwife, who was also 
taken with paralysis agitans. This patient, who was under my 
care in La Salpêtrière for many years, had experienced a violent 
pain, limited to the course of the nerves of the leg and foot. The 
parts so affected were the first seized with tremor. The pain, 
which had arisen spontaneously, and which was at times intolérable, 
resisted the most energetic remédies. It persisted until the death 
of the patient, on whom, unfortunately, no autopsy could be 
performed. 



154 PEEDISPOSING INFLUENCES. 

B. We hâve indicated the cases in whicli the influence of an 
etiological élément may be discerned ; but there are others where 
the most attentive investigations do not lead to any resuit. Hère 
we are reduced to inquire into the predisposing influences, which it 
now remains for us to review. 

In relation to the question of âge, we should point out that 
shaking palsy is not, as has been asserted, a senile disease. It is 
true that it sets in after forty, and consequeutly at a later period 
than disseminated sclerosis. This rule, however, is not absolute ; 
some instances may be cited in which the disease showed itself 
at an early âge, at twenty, for example, as in a case which M. 
Duchenne (de Boulogne) has told us of.^ 

Sex appears not to exercise any pathogenic influence ; paralysis 
agitans is found as commonly in maies as in females. 

We possess no précise information with respect to the influence 
of liereditary prédisposition. Unlike locomotor ataxia in certain 
circumstances, and progressive muscular atrophy, paralysis agitans 
is not a family disease. The observations which hâve produced a 
contrary impression relate to partial tremors that showed no ten- 
dency to become generalised, and which pertain rather to the class 
of convulsive twitchings [tics convîùlsifs) . 

There is some reason to believe that the Anglo-Saxon race (in 
England and North America) is the most subject to this disease. The 
accounts which I hâve received from physicians of the countries 
mentioned, niy personal expérience, and especially the information 
with which ray friend, M. Brown-Séquard, has supphed me, ail 
yield support to this opinion. 

But even in those countries shaking palsy is not vcri/ common. 
Dr. Sanders, in his statistical table, which comprises England and 

1 M. Fioupe has published in the ' Journal de Médecine et de Chirurgie 
Pratiques' (p. 389, 1874) the case of a young girl, under the care of Dr. 
Siredcy, who was stricken with shaking palsy at the âge of from fîfteen to 
sixteen years : " Towards the end of tlie siège of Paris she had one day taken 
refuge in a ccUar to bc out of the way of the projectiles, when a shell burst, 
destroying three or four persons at hcr side. Seized with violent terror, she 
fainted away, and when, after a few instants, she came to lier sensés, it was 
soon observcd that lier riglit arm was shakcn by a slight tremor, which in a 
little time invaded the riglit lower extremity also." She présents, at présent, 
ail the symptoms which dénote paralysis agitans : characteristic physioguomy, 
fixity of gaze, spécial attitude of hcad and body, peculiar gait, propulsion, 
rctropulbiou, &c. (B.) — Note to the Second French Edition. 



TREATMENT. 155 

Wales, aiid reaclies from 1855 to 1863, records 205 cases of death 
by paralysis agitaus — that is, an average of 22 deaths per year (four- 
teeu meu and eiglit women) . Finally^ tliis disease figures in the 
fifth place, side by side witli locomotor ataxia, on the etiological 
list of affections treated at La Salpêtricre. 

Treaiment. — A few words, in conclusion, gentlemen, upon thera- 
peutical remédies. It is an incontestable fact that paralysis agitans 
is sometimes cured. Does this cure take place spontaneously, or 
because of the remédies employed ? The latter hypothesis is but 
little probable, so far as the majority of thèse fortunate cases are 
concerned, for the same drugs, to which the crédit of effecting the 
cure in such cases, lias been given, hâve completely failed in other 
cases. EUiotson administered carbonate of iron, and Brown-Séquard 
chloride of barium — each of them had a success to chronicle, and, 
along with that, cases in which the results were négative. M. 
Duchenne (de Boulogne) has likewise to record the cure of one of 
his patients. Thèse instances prove that paralysis agitans is not 
incurable. But we must eonfess that we are ignorant of the means 
employed by nature to ])roduce this resuit. 

Everything, or almost everything, has been tried against this 
disease. Among the médicinal substances that bave been extolled, 
and which T hâve administered wH.hout any bénéficiai effect, I need 
only enumerate a few. Strychnine, praised by Trousseau (' Journal 
de Beau '), appears to me rather to exasperate the trembling than 
to calm it. Ergot of rye and belladomia, recommended on account 
of their anti-convulsive qualifies, hâve not yielded any very profit- 
able results. The same verdict must be given in référence to opium, 
which, on the contrary, augments reflex excitability, and which was 
supposed capable of moderating the tremor because of diminishing 
the pain. Latterly I hâve made use of hyoscyamine, from which 
some patients hâve obtained relief; its action, however, is simply 
palliative. 

Ogle gave Calabar bean without any advantage. As to nitrate 
of silver it has always appeared to us to exaggerate the convulsive 
condition, and this is the more remarkable, because in disseminated 
sclerosis it sometimes produces a fairly marked amendment, and 
diminishes the intensity of the shaking.^ 

1 M. Eulenberg has recently recommended the hypoderraic injection of a 
solution composed of one part of arseuiate of potash to two parts of water 
(' Berliner Klin. Wochenschr./ Nov., 1872). This mode of treatment, having 



156 TEEATMENT. 

Finally, we should mention the application of electricity, which, 
-according to some physicians^ lias brought about several cures. 
Neither statical electricity nor the interrupted curreut is recom- 
mended. Thèse agents, though of benefit, it is said^ in chorea are, 
at least according to Dr. Gull, inefficient as against paralysis agitans. 
The continued current of a galvanic pile is prescribed. It is not 
necessary, gentlemen, to remind you to-day that the physiological 
^nd therapeutical effects differ remarkably as you make use of one 
or other of thèse kinds of currents. However it be, there are at 
least tvvo cases in which this method of treatment seems to hâve 
proved successfnl.. The first pertains to Eemak, the second to Dr. 
Eussell E,eynolds. It is proper, therefore, when the occasion ofPers, 
to hâve recourse to the continued current. 

been tried by us iu M. Charcot's wards, gave no satisfactory results (' Progrès 
Médical,' 1874, p. 245). We hâve also prescribed bromide of camplior in the 
case of two patients iu the same ward, vphose disease liad lasted for several 
years. In tbe first weeks there was amendment of some symptoms, but this im- 
provement did not persist. It niight, perhaps, be well to recur to this thera- 
peutic agent in less advanced cases. (B.) — Note to the Second French Edition. 



LECTURE YI. 

DISSEMINATED SCLEROSIS. PATHOLOGICAL ANATOMï. 

SuMMAEY. — Hisfori/ of disseminated sclerosis ; Freiich periocl ; 
German period ; New French investigations ; Macroscopic 
morhid anatomy ; external aspect of tlie patches of sclerosis ; 
iheir distribution in hrain, cereheUum, protuberantia, hidbus 
raclàdicus, and sjnnal cord. Patc/ies of sclerosis on tlie nerves. 
Spinal, cephalic or bulbar, and cerebro- spinal f omis. Characters 
of the sclerosed patelles ; tJieir colour, consistence, 8fc. 

3Iicroscopic anatomy ; sTcetch of the normal histology of 
the spinal cord ; Nerve-tubes ; Neuroglia, ifs distribution ; Cor- 
tical layer of the reticulmn. Characters of the neuroglia, 
influence of chromlc acid. Arterial capillaries. Hisiological 
cjiaracters of the sclerosed patches ; transverse sections ; péri" 
^heral zone ; transition zone ; central région. Longitudinal 
sections. Altérations of the blood-vessels. Examination ofthe 
sclerosed patches in thefresh state. liistological lésions consecio- 
tive on section of the nerves. Fatty granulations in sections 
of the sclerosed 2^(f'tches observed in the fresh state. Modi- 
fications of the nerve-cells. Mode of succession of the lésions. 

Gentlemen, — At our last conférence I dwelt upon tlie distinction 
whicli sliould be made between the différent kinds of tremor. I 
menti oned, at the outset, that thej coukl be divided into two groups ; 
one, in which tremor is in some sort permanent ; another, in 
which tremor only supervenes on purposed movements. Then, 
proceeding from thèse notions, I cited as an example of the tremor 
characteristic of the first class, that observed in paralysis agitans, the 
history of which I traced for you. On onr way, I noted some of the 
characters which enable usj in thèse days^ to distinguish this disease 



158 HISTOEICAL SKETCH. 

from auotlier affection, previously coiifouucled witli it, iiainelj, from 
disseminated sclerosis. 

To tliis affection, wliicli offers us an example of tremulation 
belonging to the second class, i.e. a tremor wliicli only appcars under 
certain conditions, we shall dev^ote the présent and succecding lectures. 
Anatomically considered, disseminated sclerosis forms a clearly de- 
fined patliological species ; cliuically, the case is différent, and in 
this connection we shall hâve many blanlcs to fill up. Let us begin 
by a fevv words on the history of the snbject. 

HisTouicAL Note. 

Disseminated sclerosis is found mentioned, for the first time, in 
Cuveilhier^s ' Atlas d'Anatomie Pathologique/ 1835-1842, an admir- 
able work, which ought to be more frequently consulted by ail who 
désire to avoid the disappointmeut of making second-hand " dis- 
coveries" in morbid anatomy. In Parts 23 and 23 you will 
observe représentations of the lésions found in disseminated sclerosis, 
and, side by side, you can read the clinical observations which re- 
late to them. I take advantage of this opportunity to commend to 
your perusal a remarkable chapter on paraplegia. Previous to this 
epoch, so far as I am aware, there is no trace of disseminated 
sclerosis to be discovered anywhere. 

After Cruveilhier,Carswell in the article on '^ Atrophy,'' contained in 
his 'Atlas,' 183S, lias had lésions depicted which pertain to dissemi- 
nated sclerosis. But this author, who has drawn the materials of his 
work chiefly from the hospitals of Paris, does uot relate any clinical 
case in connection with this subject. Even to-day I do not belicve 
that disseminated sclerosis is known in England.i I do not find 
it indicated in any of the standard works published in that country, 
not even in Dr. Gull's valuable collection.- 

Thus, up till that time, the prnicipal documents in connection 
with this disease had been collected in Prance. Prom that period 
forth, during a lapse of several years, this question dropped into 
almost comi)lcte oblivion, and we hâve to seek in Germany for ncw 
iudicia. Ludwig Turck published, in 1855, examples of lésions 
manifestly belonging to disseminated sclerosis ; still, the physio- 
logical aspect of it alone engaged his mind ;'" llokitansky indicatcs 

' Tliis lecture was dolivercd in 1868. 

- Cases of i'aniplcgia in ' Guy's IIospitalRcports/ 1S56— iS.yS. 

^ " Beobachtungeii iiber das Leitungsvermogeii des Meuscldidcn lluclien 



PATHOLOGICAL ANATOMY. 159 

them in liis treatise ;^ iVerichs " and Valentine ^ record two observa- 
tions; Rindfleisch,^ Leyden/ and Zenker/' présent in thcir turn 
some éléments towards the solution of tlie problem. There were, 
liowever, desiderata to be supplied, and new researches were indis- 
pensable. It was at La Salpêtrière that the question of dissemi- 
nated sclerosis once more attracted attention amougst us. In 1862, 
M. Vulpian and myself placed new examples on record. M. 
Bouchard, founding his remarks on the cases collected by us at 
the Salpêtrière, reopened the subject in a treatise which he read 
before the Médical Congress at Lyons. 

In the preceding enumeration of authorities, we bave taken count 
chiefly of the works relatiug to the pathological anatomy of the sub- 
ject,^ as we propose to make mention hereafter of those wliich coutain 
clinical détails. To the items of information culled from the writers 
whose names are mentioned above, we shall add other information 
drawn from unpublished sources/ and, in order to facilitate the 
understanding of our studies, we shall place before your eyes tjbe 
anatomical préparations which we hâve preserved. 

Macroscopic Anatomy, 

Disseminated sclerosis, as I hâve informed you, gentlemen, is not an 
exclusively spinal affection. It invades the cerebrum, the pons Varolii, 
the cerebellum, the bulbus rachidicus, as well as the spinal cord. 
We shall, therefore, enumerate the altérations which are to be ob- 
served, taking the most distinctive cases, in the différent parts of 
the nervous system, viewing them first externally, then in section. 

We hâve hère to consider a comparatively coarse altération, 
and it is surprising that it should hâve escaped observation so 
long. On the plates before you, in which thèse changes are ac- 

raarks," ' Sitzungsbericlite der Kais. Akademie der Wissenscbafteii, Matb. 
Natur. Class.,' t. xvi, 1855, p. 229. 

1 'Lehrbuch der Patbolojîiscben Auatomie,' 1856, Zweiter Baud, p. 48S. 

^ 'Haeser's Arcbiv,' Band x. 

3 " TJeber die Sclérose der Gebirns uud lliickemiiarks " (' Dcutscbe Ivliuik,' 
1856, No. 14). 

'' " Histologisclie Détail zu der Grauen Degeueratiùu von Hira und Rùckeii- 
marks" (' Vircbow's Arcbiv,' JJ. xxvi, liei't und 6, p, 474). 

^ " Ueber graue Degeneratiou des PLÛckeumarks " ('Deutscbe Klinik,' No. 
13, 1867). 

^ "Ein Beitrag zur Sclérose des Hirns und lluckcnmarks " (' Zeitscbrift fur 
B,at. Mediziu,' B. xxiv, Heft 2 und 3). 



160 DISTRIBUTION OF SCLEEOSED NODULES. 

curately depicted, you see the spinal cord spotted with greyish 
patelles, liaving a more or less regular outline, but in every case 
distinctly circumscribed and contrasting widely witli tlie adjacent 
portion of the cord. (See Plates III and IV.) 

Sometimes discrète, sometimes confluent, thèse spots or patches, as 
you may easily perceive, are disseminated without any apparent order 
and as it were by chance, over the whole of the spinal cord . The medulla 
oblongata itself does not escape, — far from it (see Plate I, figs. i and 
3) ; différent portions of the encephalon are also frequently afFected. 

But we cannot content ourselves with this simple sketch, and we 
must enter upon the détails of a more regular description. At the 
outset, we should remark that a mère external examination will 
give but a very imperfect idea of the lésion. The spots or patches 
which we hâve mentioned are not superfîcial ; they constitute real 
kernels or foci which penetrate into the substance of the tissues. 
Prequently, indeed, the section itself will reveal the existence of 
other spots concealed in the interior. 

Let us first examine the encephalon. The gênerai appearance of 
the cerebrum proper has undergone no modification of form, nor, 
we may add, of colour ; for the patches are very rarely found on the 
grey substance of the convolutions. It is différent, however, as 
regards the central parts. There, in fact, we fmd the patches, 
especially on the walls of the ventricles, in the w^iite substance of 
the centrum ovale, the septum lucidum, the corpus callosum, and 
finally in certain régions of the grey matter, e.g.^ the optic thalami, 
and the corpora striata (Plate II, figs. i and 2) . 

The cerehellum generally présents only internai patches, which 
occupy especially the corpus rhomboideum (Plate I, figs. i and 2). 

The bulhns raclààicus, the pons VaroUi, and the différent dis- 
tricts of the isthmus, are very frequently affected by patches 
of sclerosis Avliich, in sucli cases, are both peripheral and deep- 
seated. When the bulbus rachidicus is attacked, the patches are 
found to affect, cither singly or simultaneously, the corpora olivaria, 
pyramidalia, restiformia, and the posterior région where the nuclei 
of origin of the bulbar nerves are disposed. As regards the pons, 
the patches generally occupy its antero-inferior aspect. If we ascend 
higher, wc see the corpora mammilaria (or albicantia) and the crura 
cerebri affected (Plate I, figs. i and 2). 

We now corne to the spinal cord. Through the pia mater we 
often perceive the grey spots which assume a rosy tint or salmon- 



SCLEROSED PATCHES ON CORD AND NEEVES. 161 

colour, ou contact "with the atmosphère. But it is especially after 
the removal of this membrane, a removal easily effected, that the 
lésions are clearly perceived. They afFect the whole of the cord, 
being found in the cervical, dorsal, and lumbar régions ; they 
invade ail the différent columns indiscriminately, are to be found on 
the sides of the fissures, and attack the grey substance as well as 
the white (Plates III and IV). 

The nerves themselves do not escape sclerosis. We see them, 
indeed, sometimes émerge from a sclerosed patch and yet remain per- 
fectly Sound ; at other times, we find them afïected, in their course, by 
sclerosed patches quite similar to those of the nerve-centres ; this is 
so, at least; as regards those parts of the nerves which lie adjacent to the 
centres, for the observations of MM. Liouville and Vulpian (which 
hâve been frequently verifled) leavc no doubt upon the subject. 

The crantai nerves that hâve been found to présent sclerosed 
patches are the optic, the olfactory, and the fifth pair. As to the 
rachidian nerves we only know that such patches hâve been observed 
on the posterior and anterior roots : but we are not aware whether 
they hâve been thus affected in their extra-spinal course (Plate I, 
figs. I and 3, a, b) . 

ï will not dwell any further, gentlemen, on the topography of 
the patches of sclerosis; still, I cannot refrain from request- 
ing your earnest attention to the interest which belongs to this 
question. 

You observe, in fact, that thèse patches, in différent cases, occupy 
very différent régions ofthe nervous centres, and it is clear that this 
variation of position should be represented by very différent 
functional disorders. It is, indeed, to this fact that the disease 
owes a large portion of its protean character. We shall return 
to this subject ; at présent, you will remark that thèse différences of 
position give rise to certain important clinical divisions. Some- 
times the patches occupy the spinal cord exclusively {spinal for m) ; 
sometimes they predominate in the encephalon [ccphalic or hnlbar 
form) ; finally, the simultaneous existence of patches in the ence- 
phalon and cord supplies the cerehro-spinal form. 

In order to close what I hâve to say respecting the macroscopic 
anatomy of the disease, it only remains for me to indicate the 
principal characters which the patches présent when considered in 
themselves. 

Sometimes they are salient, and as it were turgescent ; at other 

11 



162 MICROSCOPIC ANATOMY. 

times they are on a level witli the adjacent parts ; finally, tliey are 
sometimes depressed, when of old date. 

Tlieir colour resembles that of tlie grey oaatter, from wliicli it is 
difficult to distinguisli them ; but on contact witli tlie atmosphère 
they assume a rosy hue, and numerous vessels are observed dis- 
tributed through them. 

Thèse spots hâve a firm consistence, and, on section, présent a 
cleau surface, whence exudes a transparent lluid. 

Such, gentlemen, as regards its simple anatomy, is disseminated 
sclerosis, or sclerosis generalised in patches ; we hâve now to enter 
upon its minute histological détails. 

In order to bring to a successful issue this undertaking, whicli 
relates to facts demanding a careful exposition, I must beg you to 
grant me both your entire attention and ail your indulgence. 

MiCROScopic Anatomy. 
The method to be followed is simple. We sliould proceed 
from a considération of the normal state of the tissues ; that 
once known, it will be more easy to deduce the morbid altéra- 
tions. The preliminary knowledge of the characteristics of the 
normal state, as regards the organs and the éléments whose 
changes we wish to study, is doubtless familiar to you, and 
we might, if necessary, enter at once upon an examination of the 
intimate lésions. Nevertheless, as you are aware, the histological 
anatomy of the nervous centres is, in many respects, quite nevv ; many 
of the questions which it suggests are still disputed ; whilst, on the 
other hand, for the compréhension of pathological lésions, it is not 
a matter of indifférence to bave a more or less well-grounded opinion 
in relation to thèse questions. Thèse considérations induce us to 
reraind you, at least in a succinct manner, of certain fundamental 
facts of normal anatomy. We shall, however, occupy ourselves 
chiefly witli the spinal cord, an organ of less complexity and more 
easily studied than the brain. In order to limit the field of our 
examination we shall not delay to describe the nerve éléments, 
properly so called, whethcr tubes or cells, nor shall we dwell on 
their reciprocal relations or modes of grouping, in the formation 
of what is known as the white and grcy substances. We propose to 
eoncentrate your attention on the connective gangue (or matrix) 
which surrounds thèse éléments on every side. To this connective 
setting a high interest attaches, especially for the pathologist, because 



NORMAL HISTOLOGY. ]63 

we must attribute to it a suprême part in tlie causation of certain 
altérations of the nervous centres, and particularly in the cases which 
•at présent engage our attention.^ 

I. 

A. It "will be, I believej of advantage to inaugurate tliis study by 
:au examination of thin transparent sections, taken transversely 
from segments of the spinal cord, which hâve been properly hardened 
in dilate chromic acid and coloured with carminé. Carminé is hère a 
precious reagent. Thanks to it, certain éléments which under its 
influence assume a vivid hue are thereby set in relief, whilst 
other éléments préserve their usual appearance. Thus the gangli- 
onic cells, their nuclei, their neucleoli, and also the prolongations 
of thèse cells, are strongly coloured under the influence of this re- 
agent. The connective matrix also becomes tinted throughout its 
whole extent, but much less vividly ; as regards the nerve-tubes, 
the axis cylinder alone takes the carminé tint, whilst the medullary 
sheath completely resists its action. 

Ail the détails which this mode of préparation brings out may be 
followed on the plate, copied from Deiters,- which I hère ex- 
hibit; you will afterwards easily find theni in the very beautiful 
sections which I shall hâve passed before you for inspection, and 
which I owe to the courtesy of Dr. Lockhart Clarke. Thèse sections 
should be at first examined with a low magnifying power. 

In the préparations, as in the plate, the portions pertaining to 
the white substance of the cord seem to. you at first sight almost 
entirely composed of small regularly rounded bodies, like dises, 
placed side by side, and having ail nearly the same diameter. 
Thèse are thin cylindrical segments, resulting from section of the 
nerve-tubes, which tubes are, in that part of the cord, disposed longi- 
tudinally, having the same direction as the greater axis of the organ, 
and are hère, like the prisms of a basaltic causeway, placed parallel 
each to each. In the centres of thèse dises, which are chiefly formed 

1 It is known that t.he first studies of the connective matrix; of the 
spinal cord date from 1810, and are due to Keuffel; but it is less known that 
Cruveilhier in his article on apoplexy in the 'Dictionnaire de Médecine et de 
Chirurj^ie pratiques,' published in 1820, mentioned it : — "Le tissu cellulaire 
séreux extrêmement délié qui unit et sépare les fibres cérébrales et qui forme 
une trame excessivement tenue" {loc. cit., p. 209). 

- 0. Deiters, ' Untersuch. iiber Gehirn uud Rûckenmark,' Braunschwies-, 
1865, PI. iii, fig. 12. 



164 ON THE NEUROGLIA. 

of non-tinted medullary matter, having a brilliant and transparent 
appearance, you will see a point or rather a little globule, i. e. the 
axis cylinder, coloured carminé. 

A somewliat more careful scrutiny soon enables you to note 
that the dises in question are not exactly in contact, and that 
they are, on the contrary, more or less plainly separated, each from 
its neighbour, by an apparently homogeneous substance, which the 
carminé colours faintly, and which seems to fill like a cément ail 
the interstices that the nerve-elements leave between them. This 
substance is nothing other than the connective gangue (or matrix) 
as we called it a little while ago, the neuroglia of Virchow, and the 
reticulum of Kolliker. In studying its mode of distribution and 
arrangement, in the différent parts of the section, you will readily 
perceive that it constitutes an important portion of the mass of the 
organ. Observe, in the first place, that in the peripheral part of 
the section it forms a ring or rather a zone of some thickness, 
from which the nerve-tubes are altogether absent. This zone is 
covered externally and enveloped, as it were, by the pia mater, 
with which it contracts only some frail attachments ; it is, besides, 
perfectly distinct as regards structure from the latter membrane, 
which is composed of fibrillary connective tissue and is, therefore, 
built up qnite differently from the neuroglia. This zone has been 
carefully described by Bidder, and by Frommann,^ who term it the 
cortical layeroi the reticulum {R'mdenschlichf) ; we shall see, further 
on, that, considered from a pathological point of view, it is of 
incontestable interest. 

From the internai border of this zone or cortex we see septa 
arise and proceed, at certain intervais, which direct their course 
towards the centre of the cord, which they divide into triangular 
compartments of almost equal size, whose bases are at the circum- 
ference, and whose apices are lost in the grey matter. Each of thèse 
septa gives off secondary dissepiments, and thèse tertiary, which are 
again subdivided. Their ramifications get interwoven, crossing and 
anastomosing, so as to produce a web or network with meshes of 
unequal size. Each of the largest of thèse meshes may enclose a fas- 
ciculus of eight or ten nerve-tubes, or even more, whilst each of the 
smaller meshes usually contains only one. The reticulated character 
described becomes especially évident in those portions of the prepara- 

' C. Erommann, ' Untcrsucli.ùber die iiormale und patholog. Anatomie des- 
Uiickeiimarks/ Jena, 1864. 



ON THE NEUROGLIA, 165 

lion where, owing to tlie peculiar distribution of tlie nerve-tubes, 
the connective skeleton persists alone. 

The neuroglia plays, probably, a more important part in the grey 
substance than in tlie white ; there are, in fact, some régions almost 
exclusively formed by it, as, for instance, the borders of the central 
canal and the column of the ependyma. It is also prédominant in 
that part of the posterior cornua known as the gelatinous substance 
•of Rolando ; in the posterior commissure, which consequently takes, 
almost throughout its whole extent, a rosy tint in the préparations 
•coloured with carminé, whilst the anterior commissure, on the con- 
trary, in conséquence of the numerous transverse nerve-tubes it 
•contains, is much less affected by the reagent. In the grey sub- 
stance also, as in the white, the neuroglia présents a reticulated 
appearance ; but, in the former case, the greater intricacy of the 
trabeculse causes the meshes to be notably smaller, and the whole to 
assume the appearance of a spongy tissue. In both states, how- 
ever, it serves as a framework and support for the blood-vessels. 

B. It is incumbent on us now to investigate, by means of more 
powerful lenses, what is the histological constitution of this connective 
gangue or web, of which we only know as yet the most superficial 
appearances. Hâve we hère a common connective tissue, (laminons 
■or fibrillary) ? Certainly not. AU observers are agreed upon this 
point. But, beyond this purely négative notion, almost everything 
-ehe is disputed in the histological history of the neuroglia. How- 
ever, one opinion tends to become prévalent hère, and this opinion, 
if I may judge from impressions arising from personal observation, 
■closely approximates to the truth. According to this view the 
neuroglia would be formed, like the stroma of lymphatic glands, for 
instance, after the type of simple reticulated connective tissue (Kol- 
diker) ; that is to say, it would be essentially composed of stellate 
cells, generally poor in protoplasm, having slender prolongations, 
ramified several times, whose branches unité with other, so as to 
■4)ind into one system the several cells, and to render them, as it 
■-were, joint-partners [Kolliker,i Max Schultze, Frommann].^ In 
this for m of the connective tissue there exists but very little amor- 
•phous matter in the meshes of the reticulum, and the intermediate 
fibrillary substance, which is one of the fundamental characteristics 
<ol the laminons tissue, is completely déficient hère. 

-^ Kolliker, ' Geweblehre/ 5e Ed., Leipzig, 1867, § 108. 
" Loc. cit. 



166 ON THE NEUROGLIA. 

Let us now see wliat direct examination enables us to cliscern m 
thin sections of tlie cord liardened by cliromic acid and coloured 
with carminé. As in tlie case of the stroma of lymphatic glands, 
whicli we hâve just taken for example, it becomes us hère to distin- 
guish, in the first place, the cells, and, in the second place, a 
network of fibroid trabeculse, which binds thèse cells together. Let 
us first take note of what is observed in the white substance. The 
points of the reticulum, where several trabeculse nieet, form hère and 
there swellings or nodes of différent degrees of thickness, situated 
at almost equal distances froni each other. Now, ail thèse 
nodes, but especially those remarkable by their great size, présent 
towards their central portion a definite, rounded,- and somewhat 
oval corpuscle, more vividly coloured by carminé than the adjacent 
parts. Thèse bodies are nuclei, having a well-defined border; they 
are finely granular, are devoid of nucleoli, and measure each on an 
average from 0*004 m. to o'ooy m. They are solublein acetic acid, 
which causes them to shrink in every direction, and diminishes their 
diameter sometimes by one half ; they are known by the name of 
7niiélocytes (Ch. Eobin),^ or neiirogl'm nuclei (Virchow).- A thin 
layer of protoplasm, having no distinctly cellular appearance, usually 
surrounds thèse nuclei {imjélocytes, variété noyau), which, at other 
times, on the coutrary, are enclosed in a genuine rounded or stellate 
oeil {myélocytes, variété cellule), and furnished with more or less 
numerous prolongations (from three to ten, according to Frommann), 
of difierent lengths.'" 

The prolongations appear to unité with the trabeculaî of the 
reticulum, which continue them, as it were, without any perceptible 
line of démarcation. In cases where the cellular form is not distinct 
the nuclei, either naked or covered only with a thin layer of proto- 
plasm, look like centres whence arise the trabeculse of the reticulum, 
and whence they radiate in différent directions. 

The trabeculse should be studied in their turn, and considered 
independently of the connections they hâve either with the nuclei or 
with the cells which occupy the nodes of the reticulum ; their texture 

1 Robin, 'Programme du Cours d' Histologie,' 1864, p. 46; 'Dictionnaire 
Encyclopédique,' 2e Série, t. i, ire part; art. Lamineux, p. 284. 

- Virchow, Die Kraekhaft, Gescliwùlste, 1864-65, t. il, p. 127. 

3 In référence to tliis subject see Haycni and Magnan, 'Journal de la 
Physiologie,' &c.. No. i, 1876. Hayem, 'Études sur les diverses formes 
d'Euccplialitc,' 1868. 



ON THE NEUROGLIA. 167 

varies somewhat, according as we examine them in transverse and 
in longitudinal sections. In the first case they hâve the appearance 
of thin homogeneous and brilliant dissepiments of a fibroid nature. 
Anastomosing, they form meslies, the smallest of whicli is still large 
enough to enclose a nerve-tube. Suppose we observe a longitu- 
dinal section ? The trabeculse are seen to ramify to an indefinite 
extent, and produce a network having much finer meshes, This 
network is disposed in the form of dissepiments, which separate the 
nerve-tubes from each other and enclose them, like a sheath. The 
interstices which exist hère and there between thèse sheaths and 
the nerve-tubes seem to be filled up by a small quantity of finely 
granular amorphous matter. In the normal state we meet nowhere, 
amongst thèse trabeculee, with the slender fibrillse which constitute 
an intégral part of laminons tissue.^ 

In the grey substance the neuroglia is disposed on the same 
gênerai plan ; the meshes of the fibroid network are, however, and 
especially in parts where the nerve-elements disappear, more serried 
than in the white substance, and from this cause a spongy appear- 
ance results, which we hâve already noticed. Let us add that the 
stellate cells abound in greater number than elsewhere in certain 
régions of the grey substance, and that they sometimes attain such a 
development that it becomes very difficult to distinguish them from 
nerve-cells ; but we shall hâve occasion to refer to this point again. 

A dense fibroid network, with close meshes and numerous cells, is 
found also in those parts of the white substance where no nerve- 
tubes exist, in the cortical layer {Rindenschlicht) , for example, and 
in the greater septa which arise from it. 

If we can dépend upon the preceding description it is incon- 
testable that the neuroglia deserves to be classed with the reticulated 
connective tissue type, whose essential characters we noted a little ago. 

But this description has been chiefly traced out, as you hâve not 
forgotten, from observations made on fragments of spinal cord that 
hâve been subjected to the action of chromic acid for a greater or 
less extent of time. Now, can it be asserted that the results 

^ The term tissti laniineux was applied in 1799 by Chaussier to the 'tissue 
recently and still commonly known as cellular tissue^ which we now call con- 
nective tissue. Professer Robin still makes use of Chaussier's term, alleging 
it to be the best, because he says the ultimate éléments of this tissue are 
long filaments, somewhat flattened, thin, slender, soft and hyaline, smootb, 
slightly elastic, fasciculated. (Sigerson.) 



ÎG8 ON THE NEUROGLIA. 

obtained by tbis method of préparation are beyond tbe reacb of 
•criticism ? Such is not the opinion of some authors, amongst whom 
we must cite, in the foremost place, such masters as Henle and 
>Ch. Eobin.^ According to thèse, the fibroid reticulum, above 
described, has no real existence, but is an artificial product. 

In the fresh state, before the application of reagents, the spaces 
between the nerve-tubes are fiUed (according to them), not by solid 
trabeculse, arranged so as to form the meshes of a network, but 
«imply by a soft, greyish, finely granular substance, in the midst 
■of which the myelocytes are, as it were, held in suspension. 

This substance has the property of hardening, without loss of 
volume, under the influence of alcohol and différent reagents, of 
chromic acid in particular ; and it is owiug to this circumstance that 
it présents a reticulated appearance in préparations treated by the 
iatter reagent. To thèse objections, arguments or rather facts hâve 
•been opposed, some of which possess, we think, almost absolute 
authority. It is conceded that in the normal state an amorphous 
matter exists, interposed between the nerve-elements, though in 
scanty proportion (Kolliker), and that this matter possesses the pro- 
perties which hâve been described. It is also conceded that, in the 
■fresh state, the reticulum is less distinctly defined than in préparations 
hardened by the use of acids. But it is not the less true that, even 
in the fresh state, thin sections of the white substance of the cord, 
vrhen placed in iodised sérum and dilacerated under the microscope, 
permit us clearly to discern on their borders the fibroid tractus of 
the connective tissue (Kolliker, Frommann, Schultze). This resuit, 
which it is easy to arrive at in the normal state, is still more readily 
■obtained in certain pathological conditions when the normal arrange- 
ments are exaggerated, without being radically altered (Virchow). 

This is what takes place, for instance, as we shall point out, in 
•subacute interstitial myelitis and in sclerosis proper, when the altér- 
ation has not as yet exceeded the first phases of its évolution. 

Trom ail this it has been concluded, and we thiuk the conclusion 
legitimate, that the chromic acid has no other spécifie efi'ect than to 
bring out into better relief the reticulated texture of the connective 
gangue or setting of the spinal cord. The arrangement was pre- 
viously in existence; it is not produced from nothing by the action 
of the reagent. 

In order to conclude tlie rcmarks which I hâve thought it my 
' ' Dict. Encyclopédique,' loc. cit. 



PATHOLOGICAL HISTOLOGY. 169 

duty to ofFer you, in référence to the normal histology of tlie spinal 
nerve-centre, I liave only a word to add concerning an anatomical 
peculiarity of the smaller vessels, and principally of the arterial 
«apillaries, in the substance of this organ. They possess, like the 
intra-encephalic arterioles, that supernumerary coat whick is com- 
monly known as the lymphatic sheath or Robin's sheath. 
This sheath is separated, as you are aware, from the adventitious 
coat by a free space, fiUed by a transparent fluid in which float 
some definite éléments. You will soon recognise the interest be- 
longing to this anatomical arrangement, wli^n we corne to the 
question of iuterpreting certain lésions.^ 

II. 

After thèse preliminaries, it becomes easy for us, gentlemen, to 
enter upon the study of the histological altérations of the spinal 
cord in dissemhiatecl sclerosis. The description of thèse changes, 

' Silice this lecture was delivered, several works liave been pnblished on the 
structure of the ueuroglia (see ia référence to this subject a critical review by 
Gombault, ' Archives de Physiologie,' 1873, p. 458). In an important work, 
M. Ranvier, whose labours liave contributed so much to our knowledge of the 
connective tissue, bas shown that the cells, described by Golgi aud Boll, are 
probablj artificial products, due to the preparatory method adopted. The 
connective tissue of the nerve-centres is but little différent in structure from 
that of other régions (Ranvier, " Sur les éléments conjonctifs de la moelle 
épinière," in ' Comptes-Rendus de l'Académie des Sciences,' Décembre, 1873). 
The neuroglia is composed of little connective bundles of from o'ooi mm. to 
O"oo2 mm. in diameter. "They do uot anastomose," says M. Ranvier, "but 
in some points they cross each other to the number of four, five, six, seven, 
eight, and even more. At this crossing there is often a round or oval 
nucleus, having little nucleoli, which is flattened and surrounded by a 
granular zone. With a good immersion object-glass, magnifying from 600 
to 800 diameters, it is easy to perceive ail tliese détails and to discern in the 
granular zone a lamina cf protoplasm which, with the nucleus, constitutes a 
little flat cell of the connective tissue. Beneath and above this cell tiie little 
fasciculi follow each other. It does not seem doubtful to me," ]\I. Ranvier 
adds, "that this groupiug bas been taken for a ramiûed cell; but that is an 
error which will be abandoned, I am sure, by ail who accurately follow the 
same method " (which lie indicates). On other points of the same préparation 
may be seen isolated flat cells, and again (stellate) crossiugs without cells ; 
thèse appearances leave no doubt as to wliat should be the proper interpréta- 
tion of the foregoing facts. The reader will be less surprised at the nunierous 
conflicting opinions published as regards the neuroglia, if he recall the 
numerous discussions excited by the question of the structure of the con- 
nective tissue of the peripheral organs. The real nature of this structure 
lias been only revealed by récent researches. {Note to the Second Edition.) 



170 PATHOLOGICAL HISTOLOGY. 

wliicli we are about to give^ will be based^ principally, ou the results 
of the investigations to which M. Yulpian and myself hâve long 
devoted our attention. We shall also hâve several opportunities of 
using, after due revision, the researches made, previously or since, on 
the same subject by Valentiner,^ Eindfleisch," Zenker/ and espe- 
cially by rrommauii,^ who, in référence to.the examination ofasmall 
fragment of spinal cord, lias written a large volume, adorned with 
remarkable plates, and enriched with valuable documents. 

We shall describe in the first place the aj^pearances which may 
be discerned : i°, on trans verse sections ; and 2°, on longitudinal 
sections of fragments of the cord hardened by chromic acid. Then 
we shall describe, from the examination of fresh spécimens, certain 
pecuharities which are not observable in hardened sections. In both 
cases the coloration of the parts, eflected by means of the ammo- 
niacal solution of carminé, will be hère, as well as in the case of 
normal spécimens, an auxiiiary of great utility of which it is proper 
to avail ourselves. 

A. When you examine with the naked eye a segment of spinal 
cord affected by a patch of scier osis, the morbid part appears 
divided from the healthy portion, in an abrupt manner, without 
transition, by a definite line of démarcation. Now this is an illu- 
sion. Microscopical examination, even when a low power is used, 
enables us to state that the apparently healthy région bordering 
the sclerosed patch really présents, to a certain width, very plain 
traces of altération. When you pass the apparent limit of the 
Sound parts the lésions become more marked and they augment 
gradually in intensity as you approach the centre of the patch, 
where they acquire their highest degree of development. Whilst 
proceeding thus, from the circumference to the centre, we are led to 
recognise the existence of several concentric zones, which answer to 
the principal phases of the altération.^ 

a. In the peripheral zone the following appearances are ob- 
served : — The trabecuUc of the reticulum are markedly thickened ; 

' Valenliner, ' Deutsche Klinik,' 1856, p. 149. 

- Jiindfleiscli, ' Vircliow's Archiv,' 1863, t. xxvi, p. 474. 

■' Zcnker, ' Zeitscli. der llation, Mediz.,' 1865, Bd. xxiii, 3 Tlcili., p. 226. 

■* Frommanii, 2 Theil, Jena, 1867; sec also Rokitansky, ' Sitzungsber.,' 
K. M. Klasse, t. xiii, 1851, p. 136; Cliarcot, 'Soc. de Biologie/ 1868; 
Bouchard, 'Soc. Anat.,' 1868; Ilayem, 'Études,' &c., loc. ciL, "p. ici. 

* Cbarcot, ' Société de Biologie,' 1868. 



rATHOLOGICAL HISTOLOGY. 171 

sometimes thev hâve acquirecl a diameter twice as great as that pos- 
sessed in the normal state. At the same time^ the nuclei which 
occupy llie nodes of the reticulum hâve become more voluminous ; 
they are occasionally found to hâve multiplied and you may count 
two, or three nuclei, rarely more, in each node j^ the cellular form 
becomes more distinct, owing to tlie thickening of the trabeculse ; 
the nerve-tnbes appear to be farther apart each from each — in 
reality, they hâve chiefly diminished in volume, and this kind of 
atrophy goes on at the expense of the medullary sheath, for the 
axis-cylinder has preserved its normal diameter, or it may even be 
hypertrophied. The amorphous matter wliicli surrounds the fibres of 
the reticulum, on ail sides, appears to be more abundant than in the 
healthy state.- 

h. The nerve-tubes in the second zone, which may also be called 
the transition zone, hâve become still more slender. Many of them 
seem to hâve disappeared ; in reality, they hâve been merely deprived 
of their medullary sheaths, and are now only represented by their 
axis-cylinders, which, indeed, sometimes acquire comparativelv 
colossal dimensions.^ As to the trabeculœ of the reticulum, thèse 
ofFer not less remarkable altérations. They hâve become more 
transparent, their outlines are less distinct ; finally, in certain parts, 
and this is a really fundamental fact, they are replaced by bundles of 
long and slender fibrils, closely analogous to those which charac- 
terise common connective tissue (laminons tissue). Thèse fibrils 
are disposed in a direction parallel to the greater axis of the nerve- 
tubes ; hence but little of them is seen in transverse sections, except 
their extremities which présent the appearance of a multitude of 
very fine dots. They tend, we hâve said, to usurp the place of the 
fibres or trabeculse of the reticulum ; but they, also, invade the 
meshes which contain the Jierve-tubes, according as thèse diminish 
in size by loss of medullary mater, so that the reticulated or alve- 
olar appearance which the connective gangue or matrix shows so 
distinctly in the healthy state, teudsto become more and more effaced.^ 

c. The central région of the sclerosed patch, you are aware, is 
that in which the most marked altérations are observed. Hère ail 

* Occa&iouully some of thèse nuclei présent towards their middle région au 
indentation which seems to indicate the beginniug of scission. 
' Erommaun, 2 Theil, PL ii, fig. 1, and passim. 
^ Prommanu, Charcot. 
^ Erommaun, 2 Theil, loc. cit.. Pi. iv, figs. i, 2, 3. 



172 PATHOLOGICAL HISTOLOGY. 

vestige of fibroid reticulum lias disappeared ; we no longer meet 
with distinct trabeculœ or cell-forms ; the nuclei are less numerous 
and less voluminous tlian in the external zones; tliey are shrunken 
in every direction, appear shrivelled, and do not take so deep a 
tint as usual under tlie action of carminé.^ They may be observed 
forming little groups hère and there in the interspaces betvreen the 
bundles of fibrillœ. The latter, however, hâve invaded every part. 
They now fill up the alveolar spaces, from which the medullary 
matter has completely disappeared. Nevertheless, a certain number 
of axis-cylinders, those last vestiges of the nerve-tubes, still per- 
sist in the midst of the fibrils ; but they, in gênerai, no longer 
retain that comparatively large volume they occasionally possessed 
in the early phases of the altération ; most of them, indeed, hâve 
even diminished to such a degree that they might be mistaken, so 
close is the resemblance, for the fibril filaments of new formation, 
from which, however, we shall soon learn how to discriminate them. 

Such, gentlemen, is the final term of the morbid process, in that 
form of sclerosis which engages our attention. And this indefinite 
persistence, as we may call it, of a certain number of axis-cylinders 
in the midst of parts which hâve undergone the extrême of fibrillary 
metamorphosis, is, you will be careful to remark, a character which 
seems proper to disseminated sclerosis. It is certainly not observed, 
at least to the same extent, in theother varieties of grey induration, 
whether we hâve to deal witli descending spinal sclerosis, consécutive 
on lésions of the brain, or with that which, primarily occupying 
the posterior columns, is justly considered to be the anatomical suh- 
stratum of progressive locomotor ataxia. 

B. The results of the examination of longitudinal sections con- 
firm, on the whole, the data which hâve been laid before you : I may, 
therefore, spare you any lengthy détails, and confine myself to the 
following observations which will make you better acquainted with 
some aspects of the neoplastic fibril-formation. In sections of the 
kind mentioncdjthe characteristics of this tissue arewell seen,and hère 
you can best observe the longitudinal direction of the fibrils, their 
brilliant appcarance which makes them resemble elastic fibres, and 
their arrangement in slightly undulating and ever parallel fascicles. 
On dilacerating thèse bundles, you will notice that the fibrils of 
which they are composed are extremcly thin, that they are opaque 
and smooth, that they seldom divide and anastomose, whilst, on the 
' yroniinann, Charcot. 



PATHOLOGICAL EISTOLOGY. 173- 

contrary, tliey are frequently interwoven and entangled, so as ta 
form a kind of felted tissue, and finally that they are scarcely tinted 
by the action of carminé (fig. 9). The latter characters sufficiently 




FiG. 9 represents a fresh préparation, takeu from the ceutre of a patch of 
sclerosis, coloured with carminé, and dilacerated. lu the centre is seen a 
capillary vessel, supporting several uuclei. To the right and let't of this 
are axis-cyliaders, some voluminous, others of very sinall diameter, and 
ail deprived of their medullary sheatlis. The capillary vessel and the 
axis-cylinders were vividly coloured by tlie carminé ; the axis-cylinders 
présent perfectly smooth borders, without ramilication. Between them 
are seeu slender fibrilloe of récent formation, whicli form on the left aud in the 
centre a sort of network resulting from the entanglement or anastomosis 
of the fibrils. Thèse are distiuguished from tlie axis-cylinders, 1° by 
their diameter, which is much smaller ; 2° by the ramifications which 
they présent in their course ; 3° by taking no coloration from carminé, 
Nuclei are seen scattered about ; some of them appear to be in connection 
with the connective fibrils ; others hâve assumed an irregular form, owin"- 
to the action of the ammoniacal solution of carminé. 

distinguisli them from the axis-cylinders which, moreover, are gene- 
rally larger, translucid, and never ramified. They raay also be 
easily discriniinated from the fibres of the reticulum, with which 
they are sometimes mingled, inasmuch as the latter are thicker, 
shorter, and their borders bristle with branching processes ; finally. 



174 rATHOLOOTCAL HISTOLOGY. 

they differ from the elastic fibres wliicli are so often found in common 
con'nective tissue by an important cliaracter : — they swell np under 
the influence of acetic acid and forni a hyahne transparent mass, 
which cliange does not occur in the case of elastic fibres.^ 

Cau we proceed farther in the study of the fibres and endeavour 
to détermine their mode of formation ? Are they, for instance, as 
Frommann asserts, partially produced in the very substance of 
the fibres of the reticulum which they are destined soon to displace, 
and partially at the expense of the cells and tlie nuclei of the neu- 
ro.o-lia ? Do they arise, on the contrary, as others believe, either 
from the pre-existiug amorphous matter, or from a newly formed 
blastema ? In other words, is there metamorphosis or substitution ? 
The question, we think, must remain undecided yet awhilc; ail that 
we can say respecting it is that the fibrils bave sometimes seemed 
to take root in the substance of the nuclei or cells, and that this 
fact, if it were confirmed, might be cited in support of Frommann's 
thesis. 

I cannot pass over in silence the différent altérations which those 
blood-vessels undergo that traverse the nodules of sclerosis. Thèse 
changes may be well studied in the longitudinal sections of the cord, 
hardened by chromic acid. At the commencement, that is to say, 
in the peripheral zone, the parietes of thèse vessels, even of thefinest 
capillaries, appear much thickened and contain a larger number of 
nuclei than in the normal state. Nearer the centre of the nodule 
the nuclei are still more abundant, and, besides, the adventitious 
coat is replaced by several layers of fibrils quite similar to those which 
are simultaneously developed in the substance of the reticulum.- 
Lastly, at the final term of altération, the walls of the vessels 
hâve become so thickened that their calibre sufFers a notable 
diminution."' 

I should notice, in passing, the habituai ])resence of a certain 
number of amyloid corpuscles in the midst of the fibrillary tissue. 
But I should at the same timc mention the singular fact that thèse 
bodies are always Icss abundant in disseminated sclerosis than in 
the other varieties of grey induration. 

C. It is not always without difiiculty that we succced in finding, 
in spécimens which hâve not been prepared with chromic acid, ail 

1 Valcntincr, Zciikcr, loc. cit. ; Vulpian, ' Cours de la Faculté,' 1868. 

2 Vulpian, ' Cours de la Faculté.' 

3 Frommann, loc. cit. 



rATHOLOaiCAL niSTOLOGY. 175 

tlie détails which I liave just described. On tlie other liand, tlie 
fresli spécimens offer this advantage, namelj, they allow us to 
remark certain altérations wliicli would hâve passed unnoticed if we 
confined ourselves to liardcned préparations oidy. I allude hère to 
the existence of globules and granulations of an apparently fatty 
or medullâry nature, which we almost constantly^ meet with in 
more or less considérable numbers in the substance of the sclerosed 
patches in the fresh state, and which soon disappear without leav- 
ing any trace wlien the préparation has been steeped some little 
time in chromic acid. Now, gentlemen, the présence of thèse fatty 
granulations is connected with an important phase of the morbid 
process, I mean with the destruction of the nerve-tube, Ilowever, 
before entering into a discussion of this subject, I think it useful to 
begin a little further back and to recall to your memory, by a suc- 
cinct description, the modifications of structure which the peripheral 
nerves undergo when they are separated, by complète section, from 
the nervous centres. 

At the outset I would remind you that, in the peripheral nerves, 
the nerve- tubes are essentially constituted as in the spinal cord by 
a cylinder of medullâry matter and by an axis-cylinder, but that 
they also possess a sheath of connective tissue, the membrane of 
Schwann, which, according to the most récent researches,- does not 
appear to exist in the more slender tubes of the nerve-centres, or 
at least only shows itself there in a rudimentary state.^ You M'ill 
perceive in a moment that this anatomical peculiarity, though 
apparently insignificant, is not devoid of interest from the point 
of view we occupy. 

The foUowing are the phenomena to which I wished particularly 
to call your attention. Eight or ten days after section of the nerve 
there supervenes a sort of coagulation of the medullâry matter which 
breaks up into small masses, irregularly globular, with dark sinuous 
margins, showing a double outline, and having consequentiy pre- 
served ail the optical characters of myéline or medullâry substance. 

^ This fact is, at least, meutioned by ail the authors who bave studied fresh 
spécimens (Valentiner, llindfleisch). It bas uot beeu absent from any one of 
the spécimens which I bave examined uuder similar conditions. See also 
Rokitansky in 'Bericht der Akademie der Wissensch. zu Wien,' t. xxiv, 1857. 

- Frey, ' Handbuch der Histologie,' &c., 2e edit., p. 354 ; Leipzig, Schulte, 
•De Eetinse Structura/ 1867, p. 22 ; KôUiker, * Geweblehre,' 5e édit., 1867, 
t. iv, p. 257. 

* Vulj)ian, ' Leçons sur la Physiologie,' &c., p. 316. 



176 



PATÏÏOLOGIOAL HISTOLOGY. 



Segmentation making new progress, in the following days, it will soon 
be perceived that Schwann's slieath no longer contains irregular 
niasses of myéline, but globules presenting the appearance and the 
micro-chemical characters of fat. Thèse globules, which are at first 
rather large, become gradually smaller and smaller as the process of 
division goes on, and jBnally they are replaced by very fine granula- 
tions, resembling dust, that fiU the sheath of conuective tissue. 
Mingled with thèse is found a certain proportion of paler granula- 
tions of a protein nature ; and lastly, globules and granulations dis- 
appear, and Schwann's sheath, collapsing on itself, becomes so plaited 
and wrinkled that when you examine a certain number of sucli altered 
nerve-fibres, placed side by side in the field of the microscope, you 
would think you beheld a fascicle of filamentous connective tissue. 

AYhat becomes of the axis-cylinderduring thèse changes ? Composed 
as it is principally of protéine matter, it resists for a long time the 




FiG. 10. — Patch of sclerosis in tlic frcsli statc : a, lymphatic slicalli of a 
vessel distclldcd by voluminous fatty globules ; h, a vcssel divided 
transversely. Tlic adventitious coat is separated froni the lymphatic slieath 
by a free spacc, the fatty globules which distendcd the sheath having 
disappearcd; ce, fatty globules, galhered into small groups, dispersed 
lierc and thcre over the préparation. 



PATHOLOGICAL ÏÏISTOLOGY. 177 

action of the causes whicli hâve destroyed the medullary substance 
(or myéline), for it is occasionally still found in the sheath several 
weeks or even several months after section of the nerve.i 

To sum up : under the new conditions of nutrition, in which the 
nerve-tubes are placed by section of the nerve, the medullary matter 
coagulateSj then disintegrates and gives origin, on the one hand, to 
protéine molécules, and, on the other, to corpuscles which at first 
préserve the appearauce of myéline, but which, in conséquence of 
ulterior modifications, soon présent ail the characters of fatty granu- 
lations.- 

Let us now return to the patches of sclerosis. Hère we shall 
hâve to study phenomena closely analogous to those we hâve just been 
discussing. 

In the substance of the sclerosed nodule, in fresh spécimens, we al- 
most constantly meet, as already mentioned, with globules or granules 
presenting the gênerai appearauce of fatty bodies. Their number is 
sometimes considérable. They show themselves under two principal 
aspects, Some constitute comparatively voluminous masses, whose 
darkandsinuous edges bound formswhichsometimes represent irregu- 
lar oval globules, sometimes are club-like, and occasionally kidnev- 
shaped (fig. i o) . They présent a double , border like the myehne 
(or medullary matter) to which they also approximate in yet other 
respects. Other globules are true fatty droplets or granulations, 
sometimes free, sometimes aggregated so as to constitute con- 
fused heaps or cohérent clusters, otherwise called gramdar bodies, 
devoid of nuclei and of enveloping membrane." Protéine molécules 

^ See Vulpian, 'Leçons de Physiologie,' jip. 237 and 298; Eindfleisclj, 
'Lebrbuch der Pathologisch Gewebelehre,' pp. 10 et 20, 1866. 

" According to Robin, the myéline is a substance particularly rich in fatty 
])rinciples, and it may, in tins respect, be approximated to the contents of adi- 
pose cells ('Journal d'Anatomie,' 1868, No. 3, p. 309). Walter ('Virchow's 
Archiv,' 20, p. 426) bas expressed the opinion that it is constituted by an 
amalgam or mixture of fatty and albuminoid bodies, which merely become 
dissociated in cases of degeneration of the nerve-tubes. See also Rindileisch, 
loc. cit., p. 20, § 52. 

^ Besides thèse granular bodies proper [Fettkornchen Agglomeruté) may be 
found, in sclerosed patches, granular bodies having nuclei, that become coloured 
by the carminé test, and possess au enveloping membrane {Fettkoniclien 
ZeUeii) ; thèse are simply cells of the neuroglia undergoing fatty degenera- 
tion. See, in référence to the distinction to be drawn between granular bodies, 
I. Poumeau, 'Thèse de Paris,' 1866; Rokitansky, 'Bericht der Akad. der 

12 



178 PATHOLOGICAL HISTOLOGY. 

are to be seen mingled liere and there witli thèse différent granula- 
tions. Ail thèse products exactly resemble, you will observe, those 
which resuit from the disintegration of the medullary matter 
(myéline) in cases of nerve-section. 

Let us follow up thèse analogies. In the longitudinal sections 
which I place before you, you will notice, in certain parts, long trails 
of fatty granulations arranged in a direction parallel to that of the 
nerve-tubes ; i in the transverse sections they form hère and there 
little heaps, like separate islets, which correspond with tolerable 
fidelity to the position of the alveolœ. Generally, indeed, the granu- 
lations hâve broken bounds, crossed the borders of the alveohe, and 
becomè scattered over the adjacent tissues. But you cannot be 
SLirprised at this, when you remember that the nerve-tubes of the 
spinal cord are devoid of that cellular coat (Schwann's sheath) 
which, in divided nerves, encloses and contains ail the products of 
the disintegration of the medulla or myéline. The meslies of the 
reticulum and the interstices of the fibrillse offer easy ways of escape 
to the globules of myéline, as well as to the fatty granulations, by 
means of which they may permeate the tissue and spread abroad." 

Lastly, we would hâve you remark that the masses of (apparently) 
medullary matter and the fatty granulations are never met with in 
the centre of the sclerosed patch, that is, in the région where the 
work of fibrillary metamorphosis and of destruction of nerve-tubes 
lias terminated ; on the contrary, they always occupy the external 
portions of the patch,^ the peripheral and transition zones. Now, 
as you are aware, the morbid process is hère in full activity ; hère it 
is that, compressed on ail sides and straagulated by the thickening 
trabeculœ of the reticulum and afterwards by the fibrillary fascicles 
encroaching on the alveolse, the medullary cylinder gradually 
diminishes in volume and then disappears altogether, leaving the 
nerve-tube at length only represented by the axis -cylinder. The 
accumulation of medullary or fatty globules and the destruction of 
the myeline-cylinder consequently take place simultaneously ; we 

Wiss. zu Wien,' t. xxiv, 1857; Wedl, 'Rudim. of Patholog. Histolog.,' p. 
292, London, 1855. 

I It is not rare to mcct, in the aiidst of tlie fibrillse, with axis-cylindcrs 
partially denudcd, to wliicli globular masses adliere, at intervais, which havc 
the appearance of medullary matter. 

- Cliarcot, ' Société de Biologie,' 1868. 

* Ibidem. 



PATHOLOGICAL HISTOLOGY. 179 

may even add tliat tlicy procccd abreast, since the formnr ceases 
wlien the latter is concluded. The coexistence of tlie two pbenomena 
evidently cannot be fortuitous, and, takiûg note of what précèdes, it 
seems to us legitiinate to concludc tbat the meduUai'y and fatty cor- 
puscles in question are nothing other than tlie wreck and détritus 
resulting from the disintegration of the nerve-tubes.i 

What becomes afterwards of thèse fatty granulations ? They 
disappear in ail probability by absorption ; you know that no ves- 
tiges of them are discoverable in the central régions of the sclerosed 
patches. This is the place to submit to your notice a phenomenon 
which undoubtedly is connccted witli this act of absorption. In the 
préparations, which I am about to send round for inspection, you 
will observe that, in those parts wlierc the products of nerve-disin- 
tegration are fouud, the lyinphatic sheaths of the smaller vessels en- 
close within their cavities varying proportions of fatty granulations or 
even, though more rarely, of corpuscles presenting the characters of 
myéline. In certain points, thèse différent products are so abundant 
that the lymphatic sheaths are excessively distended; the vessels 
then appear to bave swollen to twice and thrice their normal size, 
and they stand out, like little white tracks visible to the naked eye, 
on the grey ground of the sclerosed patch. Nevertheless, the coats 
of thèse vessels offer no other altérations than those indicated above, 
which certainly bave no relationship with atheromatous degenera- 
tion. In short, we hâve hère to deal with a fatty infiltration of the 
lymj)hatic sheaths, and not at ail with a primary lésion of the vas- 
cular pariel es. The same ])henomenon is again met with in cérébral 
softening from arterial oblitération ; in most of the forms of primary 
or secondary sclerosis ; and, in short, in very différent affections of 
the nervous centres wliich, however, bave this in commou, tliat 
they ail détermine the fatty degeneration of the nerve-tubes. The 
true characters of this phenomenon appear to bave been suspected 
by Gull,2 and by BiUroth,"' but it bas been principally cleared up by 
M. Bouchard, in bis excellent studies on the secondary degeMerations 
of the spinal cord.* 

1 Tliis opitiiou lias been already very distinctly expressed by Eoidtansky in 
1S58. 'Eericlit,' &e., loc. cit., iSfj;. 
- " Cases of Paraplegia," ' Guy's llospital lieports,' Third Séries, 1858, t. iv. 

* ' Arcliiv der Heilkunde,' 3 Jahr., p. 47. 

* Boucliard, 'Archives Générales de Médecine,' Mars et Avril, 1S66: 
Thèses de Paris,' 1867, p. 44. 



180 YELLOW CELL-DEGENERATION. 

Tlie description wliicli lias been given you of sclerosic altération, 
disseminated in patches, relates chiefly to the wliite substance of the 
cord ; but it may be equally applied, at least in a gênerai way, to the 
grey matter. In botli substances^ in fact, the neuroglia is fashioned 
on the same mode], and the altérations effected in it do not essen- 
tially differ; consequently, after the remarks already noted, I 
shall only make spécial mention of the modification which the 
nerve-cells expérience when, on the grey substance being invaded, 
they become comprised within the area of a sclerosed patch. Thèse 
cells do not become the seat of nuclear prolifération, contrary to 
what under similar circumstances occurs in the cells of the connec- 
tive tissue whose nuclei generally multiply ; and this is, in fact, a 
characteristic which might, if needed, be a help to distinguish one 
from the other of thèse two orders of anatomical éléments. The 
nerve-cells undergo a peculiar altération which may be designated by 
the term ijelloiv degeneraiion, on account of the ochreous tint which 
they assume, and which is occasionally somewhat intense ; in this 
state they cease to be coloured by carminé as in the normal state ; 
the nucleus and the nucleolus seem to be formed by a substance 
haviiigavitreous and briUiant appearance. It is the same as regards 
the body of the cell, which, besides, appears as if composed of con- 
centric strata. 

Finally, ail parts of the cell are seized by atrophy, which may 
lead to a comparatively considérable diminution of its bulk, whilst, 
at the same time, the cell processes dwindle away and disappear.i 

lu the encephalon, and also in the optic and olfactory nerves, the 
sclerosed patches présent essentially the same characters as in the 
cord ; hence we do not think it would be of any advantage to enter 
into détails in relation to them. 

Now that we hâve reached the conclusion of our study, we may 
try to array, in their natural order of séquence, the pheno- 
meua which go to make up the altération in question, and thus 
endeavour to détermine the pathological method by which this 
morbid change is produced. 

Undoubtedly, the multiplication of nuclei and the concomitant 
hyperplasia of the reticulated fibres of the neuroglia constitute the 
initial, fundamental fact, and necessary antécédent; the dcgenera- 
tive atrophy of the nerve éléments is consécutive and secondary ; it 

' rrommann, loc. cit.; Vulpiiiii, 'Cours de la l'acuUc,' 1868; Charcol, 
' Sociclc de Biologie,' 1868. 



NATURE OF LESION. 181 

liad already beguu when tlie neuroglia gave way to the fibriilary tissue, 
thougli tlie wasting, afterwards, proceeded with greater rapidity. 
The hyperplasia of the vascular parietes plays merely au accessory 
part. 

In wliat consists the affection of the neuroglia which marks the be- 
ginning of this séries of dérangements ? It is easy to discover there 
al] the characteristics of formative irritation. But, after recognising 
the fact that disseminated sclerosis is a primary and multilocular 
chronic interstitial myelitis or encephalitis, it remains for us to 
détermine the histological characters which distinguish it from other 
forms of sclerosis of the nerve-centres, and also from several kinds 
of myelitis or encephalitis which, having their starting-point likewise 
în the neuroglia, nevertheless do not issue in fibriilary metamor- 
phosis. We will endeavour, at an opportune moment, to fulfil this 
duty. At présent, gentlemen, we hasten to leave the department of 
pathological anatomy for that of clinical observation in order to 
show you by what array of symptoms disseminated sclerosis of the 
nervous centres makes its existence known.^ 

' In a note piiblished in the ' Archives de Physiologie' (1873, p. 753), one 
of Professer Charcot's studeuts, Dr. Debove, has shown cause for the modifica- 
tion of the geuerally received opinion in référence to the histology of dissemin- 
ated sclerosis. According to his researches, the sclerosed parts are formed of 
fibrillae and of flat cells, quite similar to tlie cells of coramon connective 
tissue. He has succeeded in demonstrating this, through having employed the 
method of interstitial injections. 

Thèse facls are very différent from what was believed with respect to the 
structure of the neuroglia (see note, p. 169), before M. Ranvier demonstrated 
that the connective tissue of the nerve-centres does not essentially differ from 
that of other organs ; the only striking peculiarity being, according to M. 
Ranvier, the small diameter of the fibriilary fascicles. — {Note to the Second Freiich 
édition.') 



LECTURE VII. 

DISSEMINATED SCLEROSIS: ITS SYMPTOMATOLOGY. 

SuMMARY. — Biffèrent aspects of disseminated scier osis, comidered 
from a cUnical jwiut of view. Causes of error in dïagnosïs. 

Clinical examlnation qf a case of disseminated sclerosis. 
Tremor : tnodificatious caused therehy, in ihe handwriting ; 
characters wJdch distinguisli it from the tremor qf parali/sis 
agitans, chorea, gênerai paralijsis, and the motor incoordination 
of ataxia. 

Cephalic symptoms. Disorders of vision : diplopia, amhlyopia, 
7i)/stagm,us. Impteded tdterance. Vertigo. 

State of the inferior extremities. Paresis. Remissions. Ab- 
sence of disorders of sensihilïty. Commixiure of rare symptoms ; 
tabetic phenomena ; muscular atrophy. Permanent contracture. 
Spinal epilepsy. 

In the preceding lecture we minutely described the anatomical 
lésions of multilocular sclerosis of the nervous centres. Leaving 
aside, therefore, this portion of its history we shall proceed, to-day, 
to point out the séries of sjmptoms by which it makes its existence 
clinically known. 

I. 

A. It is singular that a morbid state which possesses so distinct 
and so striking an anatomical substratum, and which, in short, is 
not a rare disease, should hâve escaped clinical analysis for such a 
length of time. Yet nothing is siinpler, as I trust to show you, 
than to diagnose the affection in question, by the bcdside of the 
patient, at least when it lias reached its typical period of perfect 
developracnt. 

If it be asked what cause so lonc; deferred the reco2;nition of dis- 



CEEEBBO-SriNAL FORM. 183 

seminated sclerosis and its admission into nosological charts where 
it sliould occupy a place beside other better-known forms of primary 
sclerosis of tbe nervous centres, it is proper to point to the diversity 
of aspects under whicli it may be encountered in the hospitals. It 
is, in fact, an eminently polymorphic affection. 

Our anatomo-pathological studies ought to bave made you anti- 
cipate tbat it would be so. You remember that the patches or 
islets of sclerosis sometimes occupy tbe spinal cord exclusively, that 
in otlier cases tbey predominate in tbe cérébral hémisphères and 
the medulla oblongata, and that, finally, there are cases in which 
they are dispersed throughout ail the departments of the nervous 
centres. Thèse varieties of position induced us to recognise, from 
an anatomical point of view, tbe tbree following forms ; i°, the 
ceplialic form, i°, the spinal for m, and 3°, the mixed or cerehro- 
spinal form. It was easy to foresee tbat eacb of thèse forms 
would be represented by a group of symptoms peculiar to itself. 

B. Let us first, if you please, concentrate our attention on the 
cerebro-spinal form. It is, in truth, the most interesting in every 
respect and that which you will bave occasion most frequently to 
observe, in practice. Well, even when considered in this type, the 
disease may assume a variety of masks. Allow me, in support of 
this assertion, to mention an anecdote which one of my colleagues 
recently related to me. 

A very distinguished physician, one, however, who was but Httle 
familiar with tbe symptomatology of disseminated sclerosis, had 
come to visit my friend in the clinical department over which he 
présides. In order to do him honour, my colleague presented him 
a case of the new disease, — a very fine spécimen of the cerebro- 
spinal type. The patient, leaving bis bed, took a short walk down 
the ward. " This is an ataxic," said the visitor. *' Perhaps so," 
replied my colleague, "but what do you think of the rhythmical 
movements by which the hand and upper extremities are shaken ?" 
" True," said the visitor, " he is also afl'ected with chorea, or per- 
haps with paralysis agitans.'^ The patient was then questioned. 
He replied, but, in replying, showed a marked difiiculty of enuncia- 
tion ; he scanned the syllables in a very pecuHar manner ; and the 
utterance of a word was often preceded by a slight trembling of 
the lips. " I understand,^' said the physician, " you wisbed to puzzle 
me by presenting a most complicated case. Hère are symptoms 
which belong to gênerai paralysis. Pray don't proceed any further ; 



184 EEKORS IN DIAGNOSIS. 

your patient probably is a living compendium of ail nervous patho- 

logy." 

Now, gentlemen, I repeat it, this was simply a case, thougli a 
very complète one, of the cerebro-spinal form of disseminated scle- 
rosis. 

C. Paralysis agitans is especially the disease with wliicli tins 
form of sclerosis lias been the most persistently confounded, and for 
which it is, undoubtedly, still the most frequently mistaken. It was 
because of this confusion that, at the time we laboured to draw 
forth disseminated sclerosis from the chaos of chronic myelitic affec- 
tions, we urged M. Ordenstein, then one of our students, to tabulate 
in parallel columns the opposite characters that divide this disease 
from paralysis agitans, for the better understanding of the contrast.^ 
How M. Ordenstein acquitted himself of this duty is known to you, 
and I do not hesitate to déclare that his dissertation marks a serions 
progress in the clinical history of chronic diseases of the nervous 
System. 

In récent days, Herr Baerwinkel, a distinguished physician of Leip- 
zig, after having related a very interesting example of cerebro-spinal 
sclerosis, which, however, presented no tremor (as sometimes 
happens), seems to insinuate that M. Ordenstein was pleased to 
create difficulties which had no real existence, in order to give him- 
self the facile satisfaction of surmounting them. According to him, 
"there is no analogy whatever between the two diseases. Dr. Baer- 
winkel must, doubtless, hâve forgotten that in ' Canstatf s Jahres- 
bericht ' he gave, some ten years ago, the analysis of a case observed 
under Skoda's care, — in that case, paralysis agitans had been dia- 
gnosed during life, whilst, on post-mortem examination, patches of 
disseminated sclerosis were found in ail parts of the cerebro-spinal 
axis. The case appears to hâve been noted with the greatest fidelity. 
It is stated, and this point deserves remark, that the tremor, con- 
trary to what occurs in ordinary cases of paralysis agitans, only 
showed itself when voluntary movements were made, and subsided 
■when the patient was at rest.^ 

Nor can Ilerr Baerwinkel hâve overlooked the case recorded by 
Herr Zenker in Henle's Journal. Hère again the existence of multi- 

' " Sur la Paralysie Agitante et la Sclérose en Plaques Généralisée," Paris, 
1867. 
= 'Vien. Med. Halle,' 13, 1862. 



EKROES m DIÂGXOSIS. 185 

îocular sclerosis was oiily revealed bythe post-mortem examination.' 
During life^ Professor Hasse liad made a diagnosis of paralysis agi- 
tans, and yet, in the symptomatological description, tliere is stress 
laid on tlie nature of the tremor, wliich only showed itself under the 
influence of émotion or on the occasion of voluutary movements. 

Thèse examples suffice, I présume, to show you that, in spite of 
the opinion of Herr Baerwinkel, it is possible to confound the two 
diseases, since such confusion lias been committed by clinical 
observers whose skill is above ail question. 

That being established, I ara ready to concède that the différent 
•disguises assumed by disseminated sclerosis are coarse masks, and 
that to-day, when récent works- hâve illuminated the field of dia- 
gnosis, it is scarcely permissible to be caught in the snare. But it 
is time, gentlemen, to place you in a position to distinguish the 
characters by means of which cerebro-spinal disseminated sclerosis 
may be separated from those diseases which more or less closely 
resemble it. 

II. 

You are not unaware, gentlemen, of what value you must set on 
-clinical descriptions, eloquently detailed at a distance from the bed- 
side of the patient. They seldom succecd, whatever the effort, in 
doing more than giving origin to indistinct images which generally 
leave but a vague and transient impression on the mhid of the 
auditor. 

In order to avoid, as much as possible, falling into the fault I 
Lave just mentioned, I will proceed in your présence to the metho- 
dical examination of a patient who présents ail the symptoms of 
the cerebro-spinal form of disseminated sclerosis, in the period of 
perfect development. 

Mademoiselle V — , aged 31, has been suffering for about eight 
jears under the affection which forms the object of the présent study. 
Admitted to La Salpêtrière three years ago, she was bequeathed to 
me by M. Vulpian when he left this hospital, and he, at the same 
time, gave me, in référence to her case, a detailed and most valuable 

^ Zenker, 'Zeitsclirift fiir Medizin,' Band iii, Reihe, 1865, p. 228. 

- Bourneville et L. Guerard, " De la Sclérose eu Plaques Disséminées," 
Paris, 1S69 ; Bourneville, " Nouvelle Etude sur quelques Points de la Sclérose 
«n Plaques Disséminées," Paris, 1869. 



186 OF THE TREMOE. 

note. The invasion of tlie disease dates, we hâve said, from eight 
years ago ; it is therefore a case of old standing. I will tell you 
afterwards of the différent changes which characterised the early 
phases of the évolution of symptoms. For the moment I wish to 
confine myself to an analysis of her actual condition. 

One symptom which, doubtless, struck you ail from the first on 
seeing the patient enter, assisted by a nurse, was certainly the very 
spécial rhythmical tremor by which her head and limbs were violently 
agitated whilst she was walking. 

You hâve likewise noticed that when the patient sat upon a 
chair, the tremor disappeared at once and corn pletely from her upper 
and lower limbs, but only partially from the head and trunk. I 
lay stress on this latter point, whilst calling your attention to the 
fact that the new attitude, assumed by the patient, is far from being 
one of absolute rest as regards the muscles of the body and neck. 
Besides, we must make allowance for the existence of émotion which 
undeniably plays a certain part hère. I shall hâve occasion to show 
you Mademoiselle V — when reclining in bed, and in complète 
repose ; you will then be able to assure yourself of the utter absence of 
ail trace of tremor in the difïerent parts of her body. To cause the 
rhythmical agitation again to appear throughout the body, it will 
sufïîce to make the patient rise from her seat. To bring it back 
merely in a partial manner, in one of the upper extremities for 
instance, I will request her to lift a glass full of water, or a spoon, 
to her mouth. You can see that, in the several acts prescribed by 
the will, the tremor increases in direct ratio witli the extent of the 
movement executed. Thus, when the patient wishes to lift a glass 
full of water to her lips, the rhythmical agitation of the hand and 
forearm is scarcely noticeable when taking hold of the object ; but 
it becomes more and more exaggerated as the glass is brought uearer 
to the eyes ; and at length proceeds to such an extent that, at the 
moment when the goal is being attained, the glass is, as you observe, 
dashed with violence against the teeth, and the water is flung eut 
to a distance. This great disorder is not shown, I repeat, save in 
the performance of movements of a certain amplitude. As regards 
petty opérations, such as sewingor ravelling linen, the oscillations, on 
the contrary, arc almost null. Some time ago, the patient could still 
Write distinctly enough; the letters, indecd, werc tremulous, but 
perfectly readable.^ 

' We give below iwo spccimeiis of ilic liandwriting of a patient named 



OF THE TEEMOK. 187 

To sum up, ilie tremor in question onhj manifests Use!/ on the 
occasion of intentional movements of some extent ; if ceases to 

Lerutb, who succumbed to disseminated sclerosis in M. Charcot's wards, 
This woman was admitted to La Salpêtricre September 24, 1S64. In May, 
1865, M. Charcot obtained this fragment of tlie writing (fig. 13). 

PiG. 13. 






£^' 



^^ 



From the moiith of June, Leruth was placed uoder the nitrate of silver 
treatment (two milligrammes, then four, being administered). Under the in- 
fluence of this medicine the tremor diminished in a notable manner, as may be 
judged from au examiuation of the followiug spécimen of her writing (fig. 14). 



% W ^ -v^^ 




^ ^Ç Gc/^^^/^c^ 



Eemark, also, that in May, 1865, the patient was greatly fatigued after 
writing the three lines, of which a fac-similé is given above ; whilst in October 
she was able to write a dozen lines witli ease. We hâve selected, for the 
second spécimen, the first and last lines of what she wrote. 

Judging from the spécimens in our possession, it is difBcult to form an 
opinion on the characteristics of the handwriting of patients atfected with 
disseminated sclerosis. Geuerally, indeed, we hâve examined the patients at au 
advanced stage of this disease ; then it is almost impossible to obtain anything 
beyond a scribble without significance, the more so because we bave no term 
of coraparison. — (B.) 



188 OF THE TEEMOR. 

■exisi token the mrisdes are ahaudoned to complète repose. Such, 
gentlemen, is the phenomenon which I liave been led to regard as 
one of the most important chnical characters of cerebro-spinal dis- 
seminated sclerosis. I do not, indeed^ prétend to put this forward 
as a pathognomonic symptom ; I am not unaware that a tremor 
showing itself, with somewhat similar characters, is occasionally 
observed in affections other than dissemiuated sclerosis, as, for 
instance, in mercurial poisoning, in chronic cervical meningitis with 
sclerosis of the cortical layer of the cord, in primary or consécutive 
sclerosis of the latéral columns, &c. It is not, as we shall see, a 
constant symptom. But what I wish at présent to place promi- 
nently before you is the fact that, in dissemiuated sclerosis, when no 
other complication supervenes, the tremor, if it exist at ail, présents 
itself always with the characters which I hâve assigned to it. In short, 
this is a symptom which, by itself alone, w^ould sulïice to distinguish 
multilocular sclerosis of the nervous centres from some affections 
which so nearly resemble it as to render confusion possible. In 
référence to this subject I shall enter into some détails. 

The tremor oîparalj/sis agitans exists as well when the members 
are in a state of repose as when they are set in motion by the 
will. I présent a patient in whom the tremor has persisted for long 
years, without cessation or truce, during the patientas waking hours. 
It never stops save when this unfortunate woman is plunged in pro- 
found sleep. There are cases of shaking palsy where the tremor 
only shows itself intermittently, but, singularly enough, it is just in 
such cases that the tremor shows itself rather when the limbs are at 
rest, and ceases when they are set in motion by the will. You can 
perceive in another patient, whom I submit to your observation, 
this peculiar characteristic of paralysis agitans. Eemark, also, in 
both thèse women, that the head takes no share in the trerabling ; 
or, if it seem shaken by the oscillations, thèse are plainly com- 
municatcd to it by the agitation of other parts of the body, — there 
is transmission of shocks from the affected members and trunk. 
The absence of tremor of the head seems to me an almost constant 
fact in shaking palsy. I will add that in this affection the jerks are 
of much less extent, more regular, rapid, and serried, if I may so 
speak, than in multilocular sclerosis. In tlie latter, the oscillations 
are larger, and resemble, in many respects, the gesticulations of 
•chorea ; this analogy is so close that before the publication of the 
Works which hâve caused it to be admitted into clinical lists. 



MOTOE TXCOOEDINATION. ISD- 

clisseminated sclerosis has been sometimes designated under tlie 
names of rliythmic chorea and clioreiform paralysis. 

It is, however, always easy to distinguisli the 6dd and disor- 
derly movements of chorea, properly so called, from thc rhythmical 
oscillations of multilocular sclerosis. Note, firstly, that in the latter 
case, if tlie action of the upper extremity when lifting an objcct to 
the lips be considered, the main direction of the motion persists in 
spite of the obstacles caused lij thc jerics of the tremor, whicli, as 
we hâve just said, augment as the hand approaches its goal. In 
chorea, on the contrary, the viain direction of motion woidd he 
disturled from the oiUset hj contradictori/ movements, quite dis- 
proportionate in magnitude, ivhich cause the goal to he missed. 
Add to this, tliat the movements of chorea show themselves sud- 
denly and unexpectedly, when the limbs arc in a state of perfect 
rest; thus, apart from any act of the will, the choreic patient is 
seen to thrust ont his tongue, make a grimace, or abruptly raise a 
limb, &c. Now, such things are altogether unknown in multilocular 
sclerosis. 

When, in progressive locomotor ataxia (sclerosis of the posterior 
columns), the upper extreraities are afFected, we find, as regards pur- 
posed acts, incoordinated movements which, to some extent, recall the 
gesticulation of chorea, and the jerks of multilocular sclerosis, The 
danger of confounding them may be avoided by attending to the 
following characters. It is to be observed, at tlie outset, that in the 
incoordination of ataxic patients we do not, properly speaking, find 
any tremor or rhythmical jerks, but rather gesticulations of différent 
degrees of disorder, abruptness, and extent. Examine studiously, in 
the case of the patient whom I place before you, the movements of 
the hand when in the act of taking liold of a small object, and you 
will find truly characteristic peculiarities. You see how, at the 
moment of grasping, the fingers separate excessively, and are ex- 
tra vagantly extended, bendiug towards the back of the hand. Then the 
object is seized suddenly, with a dash, in an almost convulsive manner 
by the abrupt and disproportiouate flexion of ail the fingers. This is 
a symptom of ataxia ; you will never observe anything of the kind 
in disseminated sclerosis. Lastly, I would add — and this final trait 
is truly décisive — that, in ataxia, the closing of the eyes has always 
the effect of exaggerating in a very marked manner the incoordina- 
tion of the movements, whilst it does not at ail modify the rhyth- 
mical jerks of multilocular sclerosis. 



190 FEEQUENCY OP TEEMOE. 

We sliould not, liowever, forget tliat some of the symptorns of 
ataxia are found occasionally mixed up with tliose of disseminated 
sclerosisj when the sclerosed islets in certain régions of the cord 
spread over a certain height of the posterior columns. A case^ the 
history of which may be found recorded at length in Cruveilhier's 
'Atlas d^Anatomie Pathologique/ œaybecited as an example of this 
class.^ It is the case of the patient Paget. In order to grasp and 
use a pin she required to hâve lier eyes open^ otherwisc the pin 
dropped from her Angers. On a post-mortem examination, it was 
found that one of the sclerosed patches occupied a considérable 
extent of the posterior columns in the cervical enlargement of the 
cord. But I shall not now dwell at any greater length upon this 
point, to which we shall liave several opportunities of again refer- 

ring. 

We havehitherto, almost exclusively^studied the question of tremor 
in its connection with the upper limbs ; but we also kuow that it 
may affect the head^ the body, and the lower extremities. It présents 
itself in thèse différent parts, with ail the characters that we hâve 
described in référence to the upper limbs, that is to say, it is absent 
in repose^ and shows itself on the occasion of purposed movements, 
■or in case of attitudes which cannot be maintained except by the 
active and more or less energetic tension of certain muscles or sets 
of muscles. 

In order to complète the characteristics of this symptom, we must 
enter into a few détails. Tremor, gentlemen, as I long ago declared, 
is an almost constant symptom in the cerebro-spinal form of dissemi- 
nated sclerosis. It must not be forgotten, however, that exceptional 
cases exist, in which — though the fact is as yet inexplicable — no 
tremor présents itself amongst the syraptomatological group. I 
hâve myself observed several cases of this kind. But you should 
note, gentlemen, that tremor may hâve existed, to a greater or less 
extent, at a certain anterior epoch of the disease, and may hâve 
disappeared at the time when the patient ofîers himself for examina- 
tion. It is, therefore, necessary, on this account, to question with the 
greatest careth ose patients in whom this symptom is ap})arcntly absent. 

It is the rule that the tremor disappears when the members are 
immobilised by permanent contracture, at a more or less advaiiced 
period of the disease. Tiiough the tremor sometimes shows itself 
almost from the very beginniiig, yet it must be acknowledged that 

' Ciuvcilliier, ' Atlas d'Aiiutoniic Pathologique,' livraison 3(S, pp. i et ii. 



CEPHALIC SYMPTOMS. 191 

it is usually a late symptom. In conclusion^ gentlemen, it is very 
fréquent and almost customary tliat the tremor sliall net last as long 
as the disease; it grows less marked as the patients décline in strength, 
and it sometimes completely vanishes before the fatal end arrives. 

III. 

You are now acquainted, gentlemen, witli one of the most 
original and most important symptoms of sclerosis in generalised 
patches. A deeper and more circumstantial study of the case 
which we hâve before us will enable us to collect many other 
indicia which are not less valuable. We shall discover in our patient 
a whole group of symptoms, which I propose to call cepliallc, as 
opposed to spinal symptoms. This group comprises certain dis- 
orders of vision, of speech, and of intellect. 

A. Let us first apply ourselves to the question of visual dis- 
orders. Thèse are diplopia, amblyopia, and especially nystagmus. 

a. Blploina, as happeus also in locomotor ataxia, is an initial 
symptom, usually quite transient, but yet deserviug of passing 
notice. 

h. Amhlppïa, on the other hand, is a persistent, and indeed a 
more fréquent symptom of cerebro -spinal disseminated sclerosis. I 
believe I may af&rm that, contrary to what takes place in posterior 
sclerosis, it very rarely issues in complète blindness,^ This is a 
peculiarity worthy of notice, especially if you remember that patches 
of sclerosis hâve been found, after death, occupying the whole 
thickness of the nerve-trunk, in the optic nerves, in cases where, 
during life, au enfeeblement of sight simply had been noted." 
This apparent disproportion between the symptom and the lésion 
constitutes one of the most powerful arguments which can be 
invoked to show that the functional continuity of the nerve-tubes is 
not absolutely interrupted, although thèse, in their course through 
the sclerosed patches, hâve been despoiled of their medullary 
sheaths and reduced to axis-cylinders. 

1 In a case reported by M. Magnan ('Archives de Physiologie,' t. ii, p. 
765) there was papillary atropby of both eyes, with complète bliiiduess. 

^ Case of the patient, Aspasie Byr, commuiiicated by M. Vulpian. This 
observation is recorded, in extenso, in a work by M. H. Liouville, entitled 
" Observations détaillées de deux cas de sclérose en îlots multiples et disséminés 
du cerveau et de la moelle épiuière " (' Mémoires de la Société de Biologie,' 
1868, p. 231). 



192 DISOEDEES OF VISION. 

On examining the eyes witli the ophthalmoscope^ an opération 
which is generally rendered difficult by the existence of nystagmus, 
we usually find, under sucli circumstances, either almost complète 
integrity of the papilla of the optic uerve^ even when amblyopia 
is far advanced^ or a partial lésion ; or^ finally, in the rare case& 
where blindness is complète,^ total atrophy (marked by a pearly 
white coloration, and extrême tenuity of the vessels) with or without 
excavation of the papilla. 

In the case of Mademoiselle V — we hâve simply a rather marked 
amblyopia of botli eyes. No well-determiued lésion lias been dis- 
covered on ophthalmoscopic examination. It is worthy of notice 
that, in this casC;, flashes of light and sparks preceded the enfeeble- 
ment of sight. I hâve observed the same phenomena in several 
other cases of amblyopia connected with multilocular sclerosis, 

c. 'Nystagmus is a symptom of sufficiently great importance in 
diagnosis, since it is to be met with in about half the number of 
cases. It is not found, so far as I know, in locomotor ataxia^ 
save in very exceptional cases. Youmay observe that it exists, to a 
very advanced extent, in Mademoiselle V — . We hâve there, as 
you see, a quantity of little jerks or twitches, which cause the 
eyeballs to oscillate simultaneously from right to left, then from left 
to right, or inversely. There are cases in which the nystagmus is 
not présent so long as the gaze is fixed on nothing, but shows itself 
suddcnly, in a more or less manifest manner, as soon as the patients 
are asked to look attentively at any object. 

B. There is a symptom more frequentiy found than nystagmus, 
one which is almost constant in multilocular cerebro-spinal sclerosis, 
since it is noted in twenty-two out of the twenty-three cases that we 
hâve analysed, and this is a peculiar difficulté of enunciation which 
you can study in our patient, where it exists in a typical state of 
perfect development. 

The affected person speaks in a slow, drawling manner, and some- 
times almost unintelligibly. It seems as if the tongue had become 
" too thick/^ and the delivery recalls that of an individual suffering 
from incipient intoxication. A doser examination shows that the 
words are as if measured or scanned; there is a pause after every 
syllablo, and the syllables themsclves are pronounccd slowly, The 
patient hésitâtes in the articulation of lus words, but there is, pro- 

' Case quotcd by M. Magnan. 



CEPHALIO SYMPTOMS. 193 

perly speaking, nothing like stammering. Certain consonants^ l, j), 
and g, are peciiliarly ill-pronouncecl. 

There exists in the case of Mademoiselle V — , as you may observe, 
a certain slowness in the movements of the tongue ; you see that 
it is even affected by very manifest tremulation when protruded. It 
must not be supposed, however, that this is a constant phenomenon, 
for I hâve several times found that speech miglit be impeded to a 
very great extent without the tongue presenting tlie least trace of 
tremor. The tongue always, at least according to my expérience,, 
préserves its normal volume, and I hâve never seen it wrinkled on 
the surface, as may be noticed in certain cases of labio-glosso- 
laryngeal paralysis with atrophy of the lingual muscles. 

The difficulty of enunciation, at first scarcely perceptible, becomes 
gradually aggravated during the course of the disease, until the 
patientas discourse is rendered nearly incompréhensible. In some 
instances it becomes suddenly aggravated, as if in paroxysms, and 
then grows temporarily better. 

On the whole, the difficulty of speech which is observed in cérébro- 
spinal sclerosis approximates, in many respects, to the corresponding 
symptom of progressive gênerai paralysis. I even think that, in 
many cases, it would be almost impossible to distinguish between 
them, if abstraction were made of the assistance given by concomi- 
tant pheuomena. Add that the approximation may be rendered 
still doser by the circumstance that, in multilocular sclerosis, as in 
gênerai paralysis, the utterance of words is sometimes preceded, as 
you can verify in our patient, by a slight and, as it were, a convulsive 
contraction of the lips. 

However it be, this trouble in the articulation, to which I call 
your attention, is a very important symptom of multilocular sclerosis. 
It may potently contribute to settle the diagnosis, principally in those 
cases, which are indeed exceptional, where tremor of the hand and 
upper extremities is absent. 

To this symptom may successively be added, especially in. advanced 
stages of the disease, certain disorders of déglutition, of circulation, 
and even of respiration. Thèse are symptoms of progressive hulbar 
paralysis, which ought to give the alarm, because, becoming rapidly 
aggravated, they hâve sometimes suddenly and almost unexpectedly 
determined the fatal termination. On account of the interest attach- 
ing to them in prognosis, they shall form the object of a spécial 
study, 

13 



] 94 VERTIGO. 

C. Vertigo, in about three fourtlis of the cases, is one of the 
pheiiomeiia which mark the invasion of multilocular sclerosis of the 
nervoLis centres. As far as I can judge from the descriptions given 
me by the patients whom I hâve questioned, the vertigo is generally 
of the gyratory kind. AU objects seem to be whirling round with 
great rapidity, and the individual himself feels as if revolving on his 
axis. Threatened with loss of equilibrium, the patient lays hold of 
whatever is nigh him. In most cases, this giddiness returns in fits 
of short duration; sometimes, however, it persists almost witbout 
interruption for a certain period, superadded to the tremor and 
paralytic state of the members ; it often contributes considerably to 
render it almost impossible for the patient to stand erect or continue 
his titubating waik. You must take care not to confound this titu- 
bation with the uncertainty of gait which is connected with diplopia ; 
the latter ceases when the patient keeps one of his eyes closed. 

The vertigo in question is ail the more interesting because it 
belongs neither to locomotor ataxia, nor to paralysis agitans, and 
may consequently help in forming a diagnosis. 

D. Most of the patients affected by multilocular sclerosis, whom I 
hâve had occasion to observe, hâve presented at a certain stage of 
the disease a truly peculiar faciès. The look is vague and uncer- 
tainj the lips are hanging and half-open; the features hâve a stoHd 
expression, sometimes even an appearance of stupor. This dominant 
expression of the physiognomy is almost always accompanied by a 
corresponding mental state, which deserves notice. There is marked 
enfeeblement of the memory ; conceptions are formed slowly ; the in- 
tellectual and emotional faculties are blunted in their totality. The 
dominant fceling in the patients appears to be a sort of almost 
stupid indifférence in référence to ail things. It is not rare to see 
them give way to foolish laughter for no cause,^ and sometimes, on 

^ A patient, under M. Charcot's care, of whom v/e sliall hâve occasion to 
speak again, Ilortense Dr — , is frequently seized with causcless fits of laughter, 
which she cannot coutrol. Ilaviug been subjcct, before the invasion of the 
disease, to lits of angcr, she has noticcd, with regret, that they hâve incrcased 
since that period. (B.) On tlie other hand, one of two patients, whose cases 
I had an opportunity of studjing, in Professer Bcliicr's wards in the Ilôtcl 
Dieu, did not exhibit any marked intellectual disordcr, allhough she had bcen 
many years in hospital. The second patient, whose symptoms were more ad- 
vanced, seemed to wake froin a dream, when spoken to ; then, trying vaiuly to 
fix his gaze on the speaker, lie answered intelligently, but the (gradually in- 
crcasing) difficulty of enunciution madc conversation painful. (Sigcrson.) 



PSYCHIC SYMPTOMS. 195 

tlie contrary, melt into tears without reason. Nor is it rare^ amid 
tbis state of mental dépression, to find psychic disorders arise wbicli 
assume one or other of tlie classic forms of mental aliénation. 

One oftlie patients of Valentiner, usually subject to melancbolia, 
was, from timeto time, seized witli 'ambitions mania. A man, whose 
case bas been recently recorded by Dr. Leube^ looked upon him- 
self as destined to become a king_, nay^ an emperor; he boasted 
that be possessed a large number of oxen, borses, and beautiful 
mansions. He was soon, be said, about to form a matrimonial 
alliance with " a countess/' &c.^ 

Mademoiselle Y — was seized, a few weeks ago, vvitb a genuine 
fit of lypemania. Slie bad hallucinations of sigbt and hearing. She 
beheld frightful apparitions and beard voices tbreatening her witb 
tbe guillotine. She was couvinced that we wanted to poison her. 
Duriûg twenty days sbe refused ail kinds of nourisbment, and we were 
forced, during the whole of that time, to administer food by means 
of tbe stomach pump. To-day, thèse accidents bave almost entirely 
vanished. Nevertbeless, the voices are still beard from time to time. 
You see tbe patient bas been taken, during our examiuation, witb 
convulsive laughter whicli sbe cannot moderate, and wbich will 
soon be followed by a shower of tears. 

IV. 

In order to conclude the descri])tive study of the case which I 
bave presented you, gentlemen, as a type of mutilocular sclerosis 
of the nervous centres, it only remains for me to direct your atten- 
tion to the state of the lower extremities. You bave seen that 
Mademoiselle A^ — cannot rise from her seat, stand erect, or attempt 
to walk, if she be not strongly supported by two assistants. It is 
easy to note that the cause of tbis motor impotence is, principally, 
a pseudo-tetanic rigidity which bas seized on the lower extremities, 
and which, tbough very marked wben the patient is seated or reclining, 
becomes exaggerated to tbe bighest degree wben sbe attempts to 
rise or walk. 

1 " Ueber multiple iuselfôrmige Sklerose des Gehirus uiid Rûckenniarks " 
('Deutscb. Archiv,' 8 Bd., i heft, Leipzig-, fSyo, p. 14). 

- One of tbe patients, Aspasic B — , observed by M. Liouville, in M. Vul- 
pian's wards, bad ballucinations ; Rosine Spitale, wbose bistory we bave 
abridged (Bourneville et Guérard, loc. cit., p. 92) from M. Valentiner, fell into 
stupor some montbs before tbe fatal termination of tbe disease. (B.) 



1Ô6 PARESIS OF THE EXTREMITTES. 

This contracture of the lower limbsj at présent permanent, only 
mauifested itself quite recently iu the case of Mademoiselle V — ; it 
is, in fact, a symptom of the advanced stages of the disease. In 
the évolution of the morbid process it is always preceded at a con- 
sidérable distance by a paretïc sfate, presenting some peculiar 
features, witli which I will first endeavour to raake you acquainted. 

In référence to this particular point the clinical history of 
Mademoiselle Y — has been traversed by certain incidents which, 
without being exactly exceptional, still do not constitute the rule. 
Consequentiy I am forced to put it aside for the moment, reserving 
the right of soon returning to it. In the following description 
I will draw upon détails recorded in a certain number of cases 
which I hâve collected, and in which the paretic ])eriod was developed 
in accordauce with the normal conditions. 

Paresis of the Umhs. — We hâve hère a more or less marked 
décline of the motor power of the limbs, which is frequently maui- 
fested at the very outset of tbe disease, and which is not usually 
connected with any notable disturbance of sensibility. 

Generally one of the lower limbs is first and solely affected. It 
feels heavy and difîicult to move; the foot turns àt the least 
obstacle in walking, or the whole limb suddenly gives way under 
the weight of the body. The other limb is seized, sooner or later, 
in its turn ; however, as the paresis advances with extrême slowness, 
the patients are still able, for yet a long while, to walk about with 
more or less ease and to attend to their occupations, but at last 
the day comes when, owing to an aggravation of the motor paralysis, 
they may be confined to bed. The upper extremities are themselves 
invaded, either simultaneously or one after the other, usually at a 
period far removed from the invasion of the disease. Prequently in 
the commencement there are remissions; thus, it is not rare to see 
the enfeebled lower limbs résume, for a time, their original energy. 
Such remissions may even occasionally take place two or tliree 
times. I point out this peculiarity to your notice because it cer- 
tainly is not found, to the same extent, in other chronic diseases of 
the spinal cord. 

I should revert for a moment, in ordcr to lay stress on the fact, 
already noticed, of the absence of disorders of sensibility. The 
patients do, indeed, sometimes complain of formications, and of a 
feeling of numbness occupying the enfeebled limb; but thèse sym- 



UNUSUAL SYMPTOMS. 197 

ptoms are usually trausient and but little marked. Besides, it is 
easy to ascertain that cutaneous sensibilitj, in tlie afFected members, 
is almost always preserved, in ail its modes. The girdling pains^ 
the fulgurant crises, whicli play so prominent a part in the early 
stages of progressive locomotor ataxy, are absent hère. It is the 
same thing with respect to that loss of the sensé of position of 
parts, which also belongs to ataxia. This does not occur in regular 
multilocular sclerosis, and patients afFected by the latter disease can, 
with closed eyes, détermine with exactness the position which has 
beeu given to their limbs. Nor has the closure of the eyes any 
marked influence on the power of the patient to hold himself erect, 
or ou his manner of walking. His gait is uncertain, embarrassed, 
titubating, on account both of muscular weakness and of the 
tremor which, sooner or later, is superadded ; the feet, held apart in 
order to enlarge the basis of support, drag awkwardly over the 
ground, from which it is hard to raise them; When titubation is 
very much marked the patients threaten to fall at every step, and 
they do, in fact, frequently corne to the ground. The lower ex- 
tremities are not flung forward, in au abrupt manner and convul- 
sively, as we so commonly see them in sclerosis of the posterior 
columns. The sphincters are very rarely afFected by the weakness 
which invades the muscles of the limbs, and this contrasts with 
what occurs in many spinal affections, where you see, at a very early 
stage, vesicular and rectal troubles superadded to the other sym- 
ptoms. Finally, to complète the picture, we should lay stress on 
the habituai absence of trophic disorders of the muscles in the 
paraplegia connected with multilocular sclerosis. The enfeebled 
muscles préserve almost to the last their prominence and firmness ; 
tested by faradaic exploration they do not présent, at any stage, 
traces of notable enfeeblement of electric contra ctility. 

Intermixture of unusual s^nijHoms. — I made mention, as we pro- 
ceeded, of a certain number of symptoms which I took care to elimi- 
nate, because they do not belong to the regular type of the disease. 
It is necessary to inform you now, by way of corrective, that thèse 
symptoms do intermingle, in certain cases, with the ordinary pheno- 
mena of multilocular sclerosis, and even become so very prominent 
that an observer, if not forewarned on the subject, would perhaps be 
almost necessarily mistaken. Under this aspect, the record of 
Mademoiselle V — may furnish us with valuable information. I 



198 ATAXIO SYMPTOMS. 

extract, therefore^ some détails froin it, dated Mardi 34th, 1867, that 
is to say, over three years ago. At tliat period, when, indeed, 
the paresis and tremor were so far advanced in the lower limbs as to 
make it impossible for the patient to walk, except by the help of 
two assistants, the following symptoms were noted : — Wliilst walk- 
ing, the feet are slightly thrown forward, " as with ataxic patients." 
When the eyes are closed there is " exaggeration of the titubation, 
loss of equilibrium, and the patient would certainly fallif not strongly 
upheld by two assistants." In the lower limbs " tactual sensibility 
has diminished in a marked manner. The patient, with closed 
eyes, cannot tell what position has been given to her limbs. She 
expériences in them, from time to time, violent paroxysms of ful- 
gurant pains." Finally, the existence of a girdling pain has been 
noted. 

You hâve recognised, in this enumeration, nearly the whole séries 
of phenomena which serve clinically to characterise progressive 
locomotor ataxy. Some of them are to be found présent to-day in 
our patient, but they appear, generally speaking, in a very attenuated 
form, or relegated to the background. Do we mean to say that, 
even at the time when they seemed to predominate, they were of a 
nature seriously to embarrass the diagnosis ? No, decidedly not, 
and I am convinced that, in ail cases of the kind, you could avoid 
déception by bearing in mind the following observations. 

The very fact of paresis of the lower limbs (which does not exist 
in posterior sclerosis, or which, at ail events, only shows itself at an 
advanced stage) being found mixed up with the ataxic symptoms^ 
should put you on the true path. If it hâve preceded them the 
case is still clearer. You will also certainly hâve to chronicle the 
coexistence of some of the symptoms which belong only to multi- 
locular induration, namely — tremor of the extremities, impeded 
enunciation, vertigo, nystagmus, &c. It is necessary, besides, to 
clearly understand the reason why ataxic symptoms are sometimes 
manifested in the course of multilocular induration, as I announced 
above. There is hère, in my opinion, no" question of a combination 
of the elementary forms of two diseases — progressive locomotor 
ataxia and cerebro-spinal disseminated sclerosis. As for myself, I 
hâve never, in a post-mortem examination, met with the coexistence 
of multilocular grey induration and posterior fascimlated sclerosis ; 
and, without dcnyingthat such an association could exist, I believe it 
to be at least infinitely rare. It is, on the contrary, cominon cnough 



AMYOTEOPHT. 199 

for tlie sclerosed patches (wliich, as a rule, principally occupy tlie 
antero-lateral columns) to cross the postero-lateral fissures and en- 
croach on tlie posterior columns. Occasionally even, I liave seen them, 
wlien tliey vvere confluent, inv^olve a large portion of the substance 
of thèse columns throughout the whole extent of one of the régions 
of the cord, the lumbar région for instance. Now, in ail cases of 
this kind^ ataxic symptoms were manifested to différent degrees of 
intensity during life. I hâve no doubt but that a similar arrange- 
ment will one day be found to account for the fulgurant pains, the 
motor incoordination, and, in a word, for ail the phenomena of the 
same order which are stated in the record of Mademoiselle V — .^ 

Unusual symptoms of another kind may also be superadded to 
the regular symptoms of multilocular sclerosis. In several cases, 
which were otherwise well characterised, I hâve seen an atrophy of 
certain muscles, or groups of muscles, supervene, which recalled, both 
by its position and its mode of invasion, progressive muscular atrophy. 
I hâve twice had the opportunity of ascertaining the anatomical 

^ Cases of dissemiuated sclerosis, in which the posterior columns were 
iiivolved so as to occasion some of the symptoms of locomotor ataxy, are 
numerous enough. We may mention, firstly, the case of Paget, recorded by 
Cruveilhier in his ' Atlas ;' then the three cases which were related at length 
in our memoir. The first is that of the womau Broisat (dissemiuated 
sclerosis, principally occupying the posterior columns), who succumbed in M. 
Charcot's wards ; the two others, which were perhaps more characteristic, 
inasmuch as the symptoms and lésions of locomotor ataxia were more 
promiuent, were quoted from Friedreich. Finally, we will briefiy summarisc 
another case, which we noted during the siège, in M. Marrotte's wards : 

Joséphine Leg — , aged forty-six years, a silk-winder, lias been suffering for 
two years. She presented the following ataxic symptoms — diffieulty of walk- 
ing with closed eyes ; notion of position, with respect to lower limbs, greatly 
lost ; fréquent fulgurant pains in the knees and legs ; girdle pains. But, along 
with those symptoms, thèse were noted, i.e. considérable paralytic enfeeblement 
of the lower limbs ; préservation of the différent modes of sensibility in the upper 
and lower extreraities ; visual integrity. This woman succumbed to pyelo- 
cystitis, complicated with sacral escbars. Âutopsi/ : — Sclerosed patches on the 
left external motor oculi and on the optic nerves ; sclerosed patelles on the 
pons Varolii, the right superior crus cerebelli, &c. ; sclerosed patches on the 
surface of the latéral ventricles, in the interior of the centrum ovale, on the 
anterior face of the bulbus rachidicus, and in the fourth ventricle. In the 
spinal cord we found, i°, a sclerosed patch, four inches long, occupying the 
left posterior column ; 2°, another of less length and breadth on the right 
posterior column ; 3°, beneath it, another rather circumscribed patch occupying 
both posterior columns ; and 4°, on the antero-lateral surfaces of the cord, many 
small patches of sclerosis. (B.) 



200 CONTEAOTUEE OF EXTREMITIES. 

cause of this new complication ; in botli cases tlie irritative process, 
of which tbe sclerosed foci are the seat, had, in certain régions of the 
cord, extended to the nerve-cells of tlie anterior cornua of the grey 
matter, aud thèse cells had, in conséquence^ undergone great 
altérations, Now^ according to the researches which I hâve detailed 
to youj it is but little doubtful that progressive amyotrophy, whether 
protopathic or consécutive^ most frequently arises from an irritative 
lésion of the great nerve-cells^ termed motor cells. ^ 

Termanent conirackire of the Umbs, Spinal epilepsy. — It is time 
now to revert to the contracture noticeable in the lower extremities 
of the patient V — , which, at présent, constitutes a permanent pheno- 
menon that you may study as a most perfect type. This, gentlemen, 
is an habituai symptom of the advanced phases of multilocular 
sclerosis. It does not follow on paresis, suddenly and without 
transition. At a certain stage of the paretic period there supervene, 
either spontaneously or under the influence of certain excitations, 
paroxysmal phenomena, during which the lower extremities are 
stiffened in extension, whiist, at the same time, they are drawn 
together, and, as it were, adhère to each other. Thèse fits, which 
last for some hours, and occasionally for some days, are at first 
separated by intervais of greater or less length. Later on they become 
doser, and, at a given moment, permanent contracture is definitely 
established. When matters hâve reached this point, the following 
symptoms are observed — the lower extremities, as happened during 
the fits, are in extension ; the thighs are extended on the pelvis, the 
legs on the thighs ; the feet assume the attitude presented in talipes 

^ Erbstein ('Deutscbes Archiv fur Klinische Medicin,' t. x, fasc. 6, p. 595) 
lias related the history of a patient who succumbed to dissemiuated sclerosis 
(the bulbo-spinal form), iii wlioni, during life, utrophy of the anterior portion 
of the longue had becn observed. An histological examination afterwards 
showed — 1°, numerous foci of degeueration, not only interposcd between 
the fasciculi of the hypoglossal nerve at its origin, but also involving them and 
consequcntly internipliug their continuity. A section showed that the nucleus 
of the hypoglossal nerve was replaced by an islet of sclerosed lissue. 2°, 
The rauscuiar fibres of the anterior portion of the tongue had undergone fatty 
degeneration ; the lésion had iavadcd some of the muscular fasciculi at the 
base of the organ. 

In a patient namcd Vincent, who succumbed to dissemiuated sclerosis, M. 
Charcot noticed atrophy of the muscles of the tlicnar eminonce. Tlie palm of 
the liand was hollowcd out, and the tendons of the flcxor muscles were very 
plainly deûned, i^?} 



SPINAL EPILEPSY. 201 

equinus (varus) ; tlie kuees^ moreover, are so closely drawii together 
that you cannot separate them without great effort. Botli lower 
limbs are very generally affected simultaneously, and to tlie saine 
extent ; tlieir rigidity is somefcimes so marked that, in lifting one of 
them, whilst the patient is in bed, you, at the same time, lift the 
lower half of the body, ail in one pièce, as it vvere. Only in rare 
cases, and in the later stages of the diseases, does flexion of the 
thigh and leg predominate over extension. 

Permanent contracture may invade, in exceptional cases however, 
the upper extremities, which are also generally placed in forced 
extension and straitly applied to each side of the body. We hâve 
hère, gentlemen, to deal with a spasm which occupies simultaneously 
and with almost equal strength the antagonistic muscles, for, when 
the limbs are flexed, it is almost as difîicult to extend them as it is 
to bend them when they are extended. 

When the extremity of one of the feet is grasped by the hand, 
and somewhat abruptly extended on the leg, there ensues almost 
immediately throughout the whole extent of the corresponding limb 
a sort of convulsive trembling, which recalls the tremulation deter- 
rained by strychnine poisouing. This tremulation, which must not 
be confounded with the peculiar shake that supervenes on purposed 
movements, is not always limited to the limb in question; it is 
sometimes propagated to the other limb, and then the agitation may 
occasionally become so intense as to shake the whole body, and even 
the bed on which the patient reclines. It persists in some cases for 
several minutes, and even much longer, after cessation of the 
act which set it going. You may cause it to stop at once, as M. 
Brown-Séquard has shown, and as I hâve often since observed, by 
grasping, with the hand, one of the great toes of the patient and 
flexiug it suddenly and forcibly. Immediately after this opération 
the tétanie rigidity and convulsive trembling cease in both members, 
which become temporarily "perfectly supple and pliable as after 
death, before rigor mortis supervenes/^ ^ The convulsive tremula- 
tion may be determined by faradisation, by pinching the skin of the 
leg, or, more rarely, by kneading the limb, by the influence of cold, 
or by tickling the sole of the foot. It also comes on sometimes 
spontaneously, or at least apparently so, sometimes because of an 
effort made by the patient, as in vomiting, défécation, raising him- 

' Brown-Séquard, 'Archives de Physiologie,' t. i, p. 158. 



202 SPINAL EPILEPSY. 

self in bed, or getting out and placing liis foot upon the floor. It 
is also provoked by an attempt to walk, for permanent rigidity does 
not always absolutely prohibit tliis act ; the patients 'can sometimes 
hobble along on their toes^ the heel being raised from the floor. 
Finally, this tremulation may also be temporarily produced, along 
witli rigidity, even during the course of the paretic period, under 
the influence of one or other of the several modes of excitation which 
we hâve just reviewed. 

Gentlemen, the phenomenon, whose principal characters I hâve 
hère sketched, is nothing other than the spinal epilepsy described 
by M. Brown-Séquard. We observe it présent in the case of 
Mademoiselle Y — in what I hâve proposed to call the tonic form. 
This form, which is the type most commonly met with in grey mul- 
tilocular induration, may be placed in opposition to the saltatory 
form, which prédominâtes, on the contrary, in progressive locomotor 
ataxia and in some other spinal afi'ections. 

Permanent contracture of the limbs and spinal epilepsy must not 
any longer detain us. Thèse symptoms, in fact, do not exclusively 
belong to multilocular sclerosis of the nervous centres. Far from 
it. They shall, therefore, be studied apart, both generally and in 
their relations with the différent affections of the spinal cord in which 
they show themselves. 



LECTURE VIII. 

APOPLECTIFORM SEIZURES IN DISSEMINATED SCLEROSIS. 
PERIODS AND FORMS. PATHOLOGICAL PHYSIOLOGY. 
ETIOLOGY. TREATMENT. 

SuMMARY. — Ajmplectiform seîzures. TJieîr freqitency in clissemi- 
nated sclerosis. General considérations on apoplectiform 
attacks in gênerai paralysis, and in cases of circimiscribed 
cereiral lésions of old standing {hœmorrhage and ramollisse- 
ment). Fathogeny of apoplectiform seizures ; hisufficiency of 
tlie congestion theory. Sym])toms : state of tlie j}ulse ; élévation 
ofthe central température. Apoplectiform seizures in old cases 
of hemiplegia. Importance of température in diagnosis. 

Feriods in disseminated sclerosis. First, second, and third 
periods. Symptoms ofhulhar paralysis. Forms and duration of 
disseminated sclerosis. 

PatJwlogical physiology : relation hetween symptoms and 
lésions. 

Etiology, Influence of sex and âge. Hereditary -prédisposi- 
tion. Previous nervous affections. Occasional causes : pro- 
longed action of moist cold ; traumatism ; moral caiises, 

Prognosis. Treatment. 

Gentlemen, — I purpose calling your attention to- day, in the first 
place, to certain cérébral accidents wliicli may happen to complicate 
the symptomatology of cerebro-spinal disseminated sclerosis. I 
refer to apoplectiform seizures, which are occasionally encountered 
several times in the course of the disease, and which sometimes close 
the fatal scène. Thèse attacks hâve not hitherto appeared in the 
case of Mademoiselle V — , whose clinical record is otherwise so com- 
plète in most respects ; but nothing assures us that they ■will not 
some day show themselves. In fact, this is not a rare complication ; 



204 APOPLECTIFORM SEIZURES. 

I find it mentioned in about a fifth of tlie cases whicli I bave col- 
lectée!, and I bave personally observed it, in at least tbree instances.^ 

Tbe group of symptoms, wbicb constitutes an apoplectiform seizure, 
does not exclusively belong to multilocular sclerosis. It is found in 
a number of affections wbicb involve several points of tbe cérébro- 
spinal axis at once, and particularly in progressive gênerai paralysis. 
It is, indeed, in tbe latter disease tbat tbese congesiive attacJcs — as 
tbey are commonly called, at least in France — bave been specially 
studied on account of tbeir frequency. Tbey are met witb tbere in 
ail tbe varions forms wbicb tbey assume. Tbe description of sucli 
attacks, in progressive gênerai paralysis, bas given rise to numerous 
divisions and subdivisions. But, in point of fact, ail tbe varieties of 
form wbicb clinical observation bas revealed — I mean tbe graver 
kinds — may be classed as belonging to two fundamental types, 
namely — 

ist. Apoplectiform attacJcs (tbe ''pseudo-apoplexy " of Britisb 
autbors), and 

2nd. Upilej^itiform, or convuhive attaclcs. 

Tbe cbaracteristics of botb types may, bowever, be intermingled 
and confounded in tbe same paroxysm. Tbe first type only bas 
been, up to tbe présent, met witb in disseminated sclerosis ; but it 
cannot be doubted tbat, wben observations relating to tbis disease 
sball bave accumulated, tbey will enable us to fiU up tbe picture. 

Among tbe otber organic diseases of tbe nervous centres in wbicb 
apoplectiform or epileptiform attacks are frequently observed I 
sball confine myself to certain circumscribed cérébral lésions of old 
standing, and accompanied by permanent bemiplegia. Sucb are 
cérébral hcbmorrliage and hrain-softenmg wben occupying régions of 
tbe encepbalon, tbe lésion of wbicb bas tbe efFect of almost cer- 
tainly determining tbe cerebro-spinal altérations knowu under tbe 
name of descending fascïcidated scléroses. 

Between tbese partial lésions of tbe brain and progressive gênerai 
paralysis it seems, at first glance, tbat no point of contact exists. 
Ilowever, gentlemen, bere is a cbaracter wbicb brings tbem togetber : 
tbe observations of M. Magnan and tbose of Herr Westpbal bave 
sbown tbat, in gênerai paralysis, tbere is very often superadded to tbe 
lésions of periencepbalitis a sclerous altération, sometimes diffuse 

' Case III of tlie memoir of M. Vul))iaii, commuiucaled by M. Cliarcot. Case 
of tlic patient Byr (Cliarcot) ; case of Nicolas, presented to tlie Socicto de 
Biologie, by M. Joffroy. 



APOPLEOTIFOEM SEIZUPvBS. S05 

and sometimes fasciculated, wliicli occupies the cnira-cerebri^ pons 
Varoliij medulla oblongata, aud certain régions of the spinal cord, 
at the same time. Now, thèse cerebro-spinal lésions (as much on 
account of their mode of distribution as because of the pecuhar 
nature of the morbid process) deserve to be assimilated to the 
descending fasciculated scléroses consécutive on hsemorrhageor soften- 
ing of the brain. We know, on the other hand, that, in multi- 
locular sclerosis, the sclerosed patches occupy not only the spinal 
cord (see PI. III and PL lY) aud the brain proper (PI. I and PL 
II), but are likewise very commonly found in différent parts of the 
isthmus cerebri, and particularly in the bulbus rachidicus (PL I, figs. 
I and 3). You see^ by this, that the existence of irritativc lésions, dis- 
seminated nearly everywhere in the cerebro-spinal axis, but always 
présent in the isthmus cerebri, is a character common to ail those 
affections, so différent in appearance, in which the so-called congesûve 
attacks supervene. I would especially point out to your attention 
the constant existence of the bulbar lésion, which is, in ail probability, 
a prédominant élément in the production of thèse attacks. 

However this be, gentlemen, we hâve hère permanent altérations 
of slowly progressive évolution. They cannot, consequently, with- 
out the assistance of other lésions, explain the development of 
accidents which are, for the most part, suddenly produced, and 
which may rapidly disappear without leaving any trace. I am not 
unaware that many physicians, even at the présent day, put forward 
the theory of a partial sanguine congestion — a fluxion which, ac- 
cording to the needs of the case, should affect this or that portion 
of the encephalon. As regards myself, I cannot endorse this hypo- 
thesis. In order to justify my scepticism in this matter, I will appeal 
to the réminiscences of those among you who, in this hospital, vvere 
attached to the department for the insane. How many times hâve 
they not been disappoiuted in not finding, on post-mortem exami- 
nation, the congestive lésion, which they expected ? But I shall 
appeal, above ail, to the cases which I hâve had opportunities of 
collecting in my accustomed field of study. Many a time hâve I 
had occasion to see patients, long sufFering from hemiplegia, the 
resuit of brain-softening or intracephalic hsemorrhage, succumb 
to epileptiform or to apoplectiform attacks. Now, in such cases, 
no matter what attention I gave to the autopsy, I hâve ever 
found it impossible to discover, whether in the nervous centres or in 
the viscera, any récent congestive lésion, œdematous or other, which 



206 APOPLECTIFOKM SEIZURES. 

could explain the grave symptoms that had cliaracterised tlie fatal 
termination of the disease. I hâve never met with any but old 
lésions — ochreous foci, yellow patches, or foci of cellular infiltra- 
tion — on whicli depended the hemiplegia, and the secondary de- 
generations of the mesocephalon and of the cord, which are the 
conséquences of thèse partial lésions of the cérébral hémisphères. 
In short, I believe that, in the présent state of science, the absence 
of proper lésions is, anatomically speaking, a common characteristic 
of thèse attacks, whatever be the form they assume or the disease 
with which they are connected. 

In what relates to the symptomatology of the apoplectiform and 
epileptiform attacks, in order not to enter upon the détails of a 
regular description, I shall confine myself to mentioning the fol- 
lowing peculiarities. The scène generally opens unexpectedly, 
withput any marked preliminaries, sometimes by rapid and more 
or less intense obnubilation of the intellectual faculties, some- 
times by profound coma, suddenly supervening. In certain cases 
convulsions are added, which recall those of ordinary epilepsy, 
but which are usually localised in one side of the body {epilept\form 
attacks). In other instances there are no convulsions {aiwplec- 
tiform attachs). In both cases it is fréquent to find, developed 
from the outset, a more or less complète hemiplegia, sometimes with 
flaccidity, sometimes, but more rarely, with rigidity of the paralysed 
members. The symptoms may gradually grow worse in the course 
of a few days and induce death. This is usually heralded by the 
rapid development of eschars on the sacral région. If, on the 
other hand, the patient is destined to survive, the disappearance 
of the symptoms soon becomes manifest, hemiplegia is the only 
one that holds out for some time, but sooner or later it also dissi- 
pâtes without leaving any trace of its existence. 

Thèse attacks usually recur several times, generally after long 
intervais, during the course of the disease. So far as disseminated 
sclerosis is concerned, they hâve been noticed thrice in Case III 
of M. Vulpian's memoir, thrice in Zenker's case,^ and up to seven 
times in that recorded by M. Léo." In every instance, thèse fits left 
after them a notable and persistent aggravation of ail the symptoms 
of the original discase. 

The sketch wliich I hâve given you, gentlemen, would be too 
' Bournevillc et Gucrard, loc. cit., p. 112. 
2 Ibid, p. 112. 



THEEMOMETEIC RESULTS. 207 

imperfect if I did uot call your attention to tlie troubles of circu- 
lation and température whicli, as a gênerai rule, show themselves 
in the course of thèse attacks. The puise is always more or less 
accelerated; but, besides, (and this is the important point); the 
température of the central parts rises rapidly ; it may, in the hours 
immediately following the invasion, reach 38'5° C. (= 101*3 P.), 
or even 39° (= 103*2 P.), and frequently, at the endof twelve or 
twenty-four hours, it rises to 40° (=104 T.)^ ^^^ remains at this 
élévation for some hours, without necessarily entailing a fatal resuit. 
But if the patient is to survive, the température soon diminishes 
rapidly. An increase above 40° C. is almost always followed by a 
fatal termination. 

Thèse modifications of central température hâve been studied 
by Herr Westphal in the epileptiform and apoplectiform attacks 
of progressive gênerai parali/sis ; I hâve met with them again in 
the attacks which supervene in patients suffering from henùplegia 
of old standing, consécutive on hœrdorrhage or on sofiening of the 
brain. In order the better to settle your ideas upon this subject I 
think it will be useful to summarisethe détails of two cases relating 
to the last-named species. 

The first case is that of a woman, aged thirty-two years, affected by 
hemiplegia of the right side, dating from childhood. There ex- 
isted gênerai atrophy, rigidity, with shortening of the limbs, and 
paralysis, such as are generally found in like cases. This woman 
was subject to epileptiform attacks. She was brought to the in- 
firmary some hours after a more than usually severe attack. On 
the evening of her admission lier température was above 38° C. ( = 
100-4 r.) ; next day it had reached 40° C. (= 104 P.). The fits 
became subintrant; they were repeated about a hundred times a 
day. Eschars formed rapidly on the sacral région, and death 
supervened the sixth day. On that day the rectal température 
stood at 42*4° C. (= 108*32 P.). On post-mortem examination 
there was found, at the surface of the left cérébral hémisphère, 
a considérable dépression answering to a yellow patch, the remuant 
of a vast focus of ramoUisement. The whole hémisphère, more- 
over, was atrophied. No trace of a récent lésion could be found, 
neither in the nervous centres nor in the viscera. 

The second case is that of a woman, aged sixty years, afflicted 
with right hemiplegia consécutive on cérébral heemorrhage, dating 
from two years previously. This patient had already experienced 



208 THERMOMETRIC RESULTSi 

several epileptiform or apoplectiform attacks, which, however, were 
generally sliglit. One day an intense and prolonged epileptiform 
attack supervened, which was followed by an apoplectiform condition. 
Tvvo hours after the setting in of thèse accidents^ the rectal tem- 
pérature was 38*8° C. (= iOT"84r.); five hours later^ it rose to 
40° C. (= 104 P.). Next day, in spite of tlie cessation of con- 
vulsions, the température was 41° (= 105*8 F.); and the day 
following, being the day of her death, it reached 42*5° C. (= io8"5 
P.). The autopsy showed two ochreous foci, one occupying the 
corpus striatumj the other the substance of a convolution. There 
existed no récent lésion capable of explaining the accidents which 
had determined death. 

I hâve as yet had no opportuuity of following, day by day and at 
différent periods of the day, the changes of central température in 
a case of apoj}lectiforf}i seizicre supervening in a patient affected with 
dissemînated sclerosls. Nevertheless, we can gather partial results 
from différent cases, which leave no doubt that, even in this respect, 
matters proceed exactly in the same way in multilocular sclerosis, as 
in progressive gênerai paralysis and in circumscribed lésions of the 
cérébral hémisphères, Thus, the patient whose history has been 
related by Herr Zenker was, towards the close of his life, taken with 
an apoplectiform attack, followed by hemiplegia of the right side. 
Now, on the day of the seizure, his puise being at 136, the tempéra- 
ture reached 39*6° C. (= i03"28 F.). Next day, the thermometer 
marked 40° C. (=104 P.). The day after, the paralysis had ame- 
liorated and the température had fallen back to the physiological 
figure. In the case of the patient Nolle, narrated by M. Léo, an 
apoplectiform attack came on in the evening. Next morning 
early, the puise numbered 144, and the température stood at 38*5 C. 
(= ioi"3 P.). This attack, the seventh that the patient had expe- 
rienced, was to be followed on the same night by death. In the 
case of N — , whose record was compiled in my wards by M. Joffroy, 
five hours merely after the invasion of an apoplectiform attack, with in- 
couipletc loss of consciousness and gênerai resolution of the members, 
the rectal température stood at 40*3° C. (= 1 04*54 F.), and the puise 
at 1 20. Next day the apoplectiform symptoms were dissipated, and 
at the same time the puise and the température had returued to 
what they were in the normal state.^ 

If I hâve dwelt with some tenacity on the changes which the 
' 'Socictc de Biologie,' t. i, 5 série, 1869-70, p. 145. 



DISSEMINATED SCLEEOSIS : PEKIODS. 209 

température ofthe bocly présents, iii tlie apoplectiform and epilepti- 
form seizures of gênerai paralysis, and of some other cerebro-spinal 
affections, it is because, in ray judgment, we find a characteristic 
therein whicb may, in certain cases, be profitably used in diagnosis. It 
is not necessary, I tliink, to enter into a long discussion in order 
to sliow liow difficult it is, in présence of a patient who lias just 
been stricken with apoplexy, accompanied or not by convulsions, to 
décide from tlie mère contemplation of external symptoms whether 
we bave to deal with Inie apoplexij, resulting from the actual for- 
mation of a focus of cérébral hsemorrhage or of ramollissement, or 
whether, on the contrary, we hâve before us a simple congesûve 
attack. Well, an examination of the central température would 
supply, in such cases, a décisive test. I bave, in fact, demonstrated 
by repeated observations^ that in true apoplexy, especially when 
it dépends upon cérébral heemorrhage, the température constantly 
diminishes, some moments after the attack, and afterwards remains, 
generally for at least twenty-four hours, below the normal standard, 
even when intense and reiterated convulsive fits occur. Now, we 
hâve just seen that, in the so-called congestive attacks, the tempér- 
ature, on the contrary, from the invasion of the first symptoms, 
rises above the physiological standard and tends to become gradually 
more and more elevated durinsr the whole continuance of the attack. 



Peuiods and Forbis of Disseminated Sclerosis. 

Gentlemen, after having considered, one by oue, the différent 
éléments which compose the symptomatology of multilocular sclerosis 
where we bave to deal with a complète case, one which has already 
arrived at an advanced stage of its évolution, — it is next proper to 
show, in a gênerai view, how thèse éléments are grouped and arrangea 
in the différent phases and forms of the disease. The affection is, in 
truth, far from presentiug itself clothed in ail its attributes, at every 
epoch of its course. At the outset it may be constituted by the union 
of two or three symptoms only ; and, besides, there are cases where 

^ Cbarcot, " Note sur la température des parties centrales dans l'apoplexie liée 
à rhémorrhagie cérébrale et au ramollissement du cerveau," iu ' Comptes llendus 
des Séances de la Société de Biologie,' t. iv, 4c série, 1867, p. 92. See also 
Charcot, ' Leçons sur la tliermométrie clinique, publiées dans la Gazette 
hebdomadaire,' 1869, pp. 324, 742, 821 ; Bourneville, ' Études cliniques et 
thermométriques sur les Maladies du Système Nerveux,' Paris, 1870-73. 

14 



210 riEST PEEIOD. 

the symptomatic séries remains incomplète until the fatal end. Now, 
it is, especially, when the disease is yet at an early stage, or when 
it assumes an imperfect form, tliat it is important to know liow to 
lecognise it by the slightest indicia. 

I hâve proposed to establish three periods in the progressive 
development of the disease. The first extends from the moment 
when the first symptoms appear to the epocli when the spasmodic 
rigidity of the members reduces the patient to almost absoliite impo- 
tence. The second comprises the space, usually of considérable 
length, during which the patient, confined to bed, or barely able to 
take a few steps about the room, still préserves the integrity of his 
organic functions. The third commences at the moment when, ail 
the symptoms of the disease becoming simnltaneously aggravated, 
the functions of nutrition suffer in a raanifest manner. We will 
take occasion, as regards this ultimate period, to notice the disorders 
which, in the common order of things, mark the last phase of the 
disease and accelerate its fatal termination. 



First period. — The mode of invasion and of concaténation of 
symptoms présents certain varieties which deserve to be pointed ont 
to your notice. 

Sometimes, the drama is begun by the cephalic symptoms. Thus, 
the patients commence by complaining of habituai giddiness, and 
more or less transient diplopia ; little by little, difiiculty of enuncia- 
tion, and finally nystagmus, show themselves. The union of thèse 
symptoms would already constitute a sufficiently characteristic group, 
one which, even if tremor provoked by movement and paresis of the 
limbs were not superadded, should of itself enable us to establish a 
diagnosis, on strong probabilities. 

But sucli is not the most common mode of invasion. Generally, 
the spinal phenomena first reveal themselves, and so common is this 
circumstance that during many months — nay, even for years — the 
patients may présent no symptoms other than an enfeeblement, a 
more or less markcd paresis of the lower extremities, displaying a 
tendency to become aggravated, in a slowly progressive manner, and 
to extend to the uppcr extremities. In such a case, the position of 
the clinical observer is nccessarily an extremely difiicult one. For, 
in short, paresis of the lower limbs is a somewhat trite symptom, 
one common to a crowd of différent diseases ; still, it sliows itself in 



EEMISSIONS. 211 

multilocular sclerosis, as you remember, with some peculiar features 
which may indicate tlie riglit patli to follow. Thus, howevermarked 
it may be — settiug aside exceptioual cases where tlie lésion prédomi- 
nâtes in the posterior columns — it is not accompanied by any trouble 
of sensibility, nor by any perceptible disorder of nutrition in the 
muscular masses. Add to this that, as a rule, there is no functional 
dérangement of bladder or rectum. Finally, it is not rare to meet 
with remissions, and even with complète iniermissiovs, which give 
rise to hopes of a decided cure.' But it is clear that thèse 
indicia, even with the aid of ail the others, only supply very 
vague data. Certainty can hardly be secured unless the peculiar 
tremor, or some of the cephalic symptoras, are superadded to the 
spinal symptoms. 

Hitherto^ gentlemen, I hâve shown you the invasion and ulterior 
concaténation of accidents as slow and progressing in a uniform 
manner. That, in fact, is by far the most usual case; but it is 
important you should know that, in certain exceptional cir- 
cumstances, the disease may set in suddenly and unexpectedly, or 
after a few preliminary symptoms, of little significance. 

Thus, vertigo and diplopia having suddenly shown themselves, 
paresis and titubation may follow in a few days, so that the disease 
is thus, as it were, immediately established, This, to take one case 
amongst several, is what happened as regards the young woman 
named Vinch — , whom some of you may hâve seen in our wards. 

Sometimes the beginning is marked, as in the case of one of 

^ In our memoir, we summarised a certain number of cases in which 
remissions were found so complète as to enable the patients, who had been 
paralysed, to résume their occupations. (See loc. cit., obs. iv, ix, x, xi, &c.) 
In an observation recorded by M. Vulpian, which we also quoted (p. 139), 
there was a séries of alternate améliorations and aggravations. We shall 
briefly indicate them : 

When the disease was still récent, there supervened, after an attack of 
smallpox, a quasi-complete recovery. This improvement lasted for three 
years. At the end of that time, the menses were suppressed ; uew, but slight, 
symptoms showed themselves, which disappeared on restoration of the cata- 
menia. Two years after, the patient had au attack of jaundice, followed by 
new symptoms. Thèse improved, but on bronchitis superveniug, the paresis of 
the limbs re-appeared iu a more marked form, and, after successive remissions 
and recrudescences, became permanent. 

Sometimes the remission is incomplète, and only atfects certain symptoms, 
particularly incontinence of urine and of fœces. In a patient, whose case was 
uoted by Herr Baerwinkel, there was also a brief remission. (B.) 



212 GASTEIC CRISES. 

Valentiner's patients^ by an abrupt invasion of paresis in one of tlie 
lower extremities ; or again, as occurred in M. Léo's case and in that 
of one of my patients, whose liistory M. Yulpian bas related/ tbe 
invasion is inaugurated by an apoplectiform attack, preceded for 
some days or weeks, by vertigo and cephalalgia, and followed by 
temporary beiniplegia. 

Finally, gentlemen, there is yet another variety^ to wliich I must 
call your attention, where the invasion is marked by an affection wbich 
is mostly regarded as foreign to the princi])al disease, altliough it is, 
in my opinion, intimately bound up witb it, on the contrary, by a liuk 
not recognised until now. I allude- to the yastylc or gastralgie 
crises, whichever you please to call them, that are occasionally very 
severe, and are accompanied by lypothymia, by repeated vomiting, &c. 
Thèse crises hâve often opened the drama, and been quickly fol- 
lowed by the usual symptoms of multilocular sclerosis; it is not 
rare, also, to find them several times recurring and intermingling 
with thèse symptoms, during the early stage of the disease. Of this 
class, a case reported by M. Liouville ^ and that related by Herr 
Zenke furnish good examples. Thèse accidents are ail the more 
worthy of notice inasmuch as we shall find them agaiu, with nearly 
the same characters, in other forms of sclerosis of the spinal cord, 
and particularly in fasciculated posterior sclerosis {locomofor 
ataxia), but chiefly in its initial phases. In such a case, thèse 
gastric crises, coinciding or alternating with the fulgurant pains of 
the limbs, may actually be, along with diplopia and perhaps a little 
titubation when the eyes are closed, the only symptoms of the dis- 
ease in question, whose true nature is then too often misunderstood.^ 
Thèse same gastric crises are foiind, as my friend Dr. Duchenne (de 
Boulogne) and I hâve observed, in the form of suhacute or chrome 
central myelitis, which reproduces the symptoms of gênerai spinal 
paralysis. Eut I do not wish to delay any longer on this subject, 
which I intend soon to résume and to discnss in détail, as its 
importance deserves. 

' Vulpia», " Kote sur la Sclérose en Plaques de la Moelle Epinièrc," Obs. ii, 
'Mémoires de la Société Médicale des Hôpitaux,' 1869. 

- ' Mémoires de la Société de Biologie,' 5e série, l. i, p. 107, Paris, 1S70. 

^ See wliat M. Charoot lias said, in référence to tliis subjcct, in liis lectures 
delivered at La Salpctrière in 1868 (IJubois, ' Etude sur quelques points de 
l'ataxie locomotrice,' Paris, 1868, "Des crises gastriques," p. 56; 'Leçons sur 
les anomalies de l'ataxie locomotrice,' 1873, leçon ii, p. 32). 



SECOND PERIOD. 213 

II. 

Second j^erîod. — In gênerai, from the close of tlie first period, 
raultilocular sclerosis shows itself arrayed in most of tlie symptoms 
wliich characterise it. Thèse symptoms become aggravated and 
intensified daring the second period, and spasmodic contraction of the 
limbs is superadded, either with or without the accompaniment of 
spinal epilepsy, in conséquence of which the patients who, until then, 
bad been able to walk or hobble,with more or less difficulty, are thence- 
forth rendered almost quite powerless, and definitely confined to their 
rooms or beds. The contracture which marks the commencement 
of this period is almost always a very tardy symptom; it seldom 
shows itself till two, four, or even six years after the appearance of 
the first accidents of mutiiocular sclerosis. 

m. 

Thir cl period. — The commencement of this final period is marked, 
as I mentioned to y ou, by the progressive enfeeblement of the 
organic functions ; inappetency becomes habituai, diarrhœa fréquent, 
and soon a gênerai emaciation supervenes which grows more and more 
évident. 1 At the same time, there ensues an aggravation of ail the 
symptoms proper to this disease, the obnubilation of the intellect 
proceeds even to dementia, the difficulty of enunciation is carried to 
its extrême, and the patient can only utter an unintelligible grunting ; 
then the sphincters become paralysed, and it is not rare to find the 
mucous coat of the bladder aflected with ulcérons inflammation. 
Then, on the sacral région and on ail points of the lower limbs sub- 
\mitted to prolonged pressure, eschars appear which occasionally 
assume enormous dimensions, and, consecutively, cornes the whole 
séries of accidents which dépend on this complication, purulent 
burrowing sores [fusées), purulent or putrid poisoning, &c. Death 
foUows without delay. 

* At tliis period of the disease, especially, we notice the supervention 
of disorders which may, perhaps, be classed among trophic troubles. Such 
are— 1°., softening of the vertebrœ, of the troclianters, of the head of 
the tibia, of the bones of the tarsus, &c. (Bourneville et Guérard, loc. cit., 
cas du Docteur Pennock, p. 83) ; 2°., a cyphosis and (right) scoliosis, 
mentioned iu one of Friedreich's cases (B. et G., loc. cit., pp. 213 and 214) ; 
3°, an effusion of liquid into the two femoro-tibial articulations (Obs. de M. 
Malherbe). (B.) 



214 THIED PERIOD. 

In most cases the patientas existence may be abridged by some in- 
tercurrent disease ;^ pneumonia, caseous phthisis, and dysentery may 
be numbered amongst the most fréquent of thèse terminal affections." 
^ In the cases which bave sitice been published we, most usually, fiiid the 
terminal diseases indicated by M. Charcot. It foUows from the statistics 
we bave collected that pulmonary diseases (pneumonia, purulent pleurisy, 
tubercular phthisis) are by far the most prominent. We should also mention 
the occurrence of acute bed-sore, of ■pjjelo-cystltis (one case), and of œcleniu 
glotddis (one case). (B.) 

^ In this manner, the patient Vauthier (the subject of the preceding lecture) 
succumbed, and the patient Bezot, who long occupied bed No. lo, Salle St. 
Luc. We shall rapidly summarise the principal facts of their cliuical history : 
I. Vauth — (Joséphine C), was admitted March 2ist, 1867, toM. Vulpian's 
•wards, and died January 7th, 1871 (aged thirty-two), in M. Charcot's charge. 
From fourteen to twenty-one years of âge, she suffered from vertigo foUowed 
by vomiting. Pregnancy, at twenty-one, put au end to vomiting. Disseminated 
sclerosis showed itself at the âge of twenty-three years six months : weakness of 
the lumbar région, very great fatigue of the lower limbs, lancinating pain in the 
right leg, enfeeblement of the sight, diplopia. At twenty-five years, feeble- 
ness of the arms, which are occasionally affected by pains. 

1867, — Nyît^gmus, diplopia. Integrity of the muscular masses, loss of 
idea of position as regards lower limbs. Paresis and tremor of tiie upper 
extremities. Tactual sensibility largely lost everywhere. Momentary improve- 
ment under nitrate of silver. 

1868. — The patient can no longer stand erect; the symptoms are more 
marked ou the right side than on the left; the tremor of the upper ex- 
tremities has augmented. Prequent fulgurant pains, especially in the left 
half of the face. Pits of giddiness coming on at close intervais. Nystagmus 
more marked. In May, M. Vulpian administered two pills of o'025 gram. 
(ornearly \ grain) of extract of Calabar Beau. Soon after, a fit of weakness, 
tremor exaggerated, cold sweats, pallor of the face (thèse phenomena are, 
perhaps, due to the Calabar Beau). Prom July, tbree pills of Calabar Bean. 
In November, M. Vulpian suppresses the Calabar Bean, and as incontinence of 
urine has latterly supervened, he prescribes three pills of o'03 gram. (or nearly 
\ grain) of extract of Belladonna. The incontinence of urine, after presenting 
some transient improvements, ceased altogether in the course of December. 

1870 (January). — Psychic disorders (see (mtè, p. 195). In the course 
of this year the symptoms noted augmented in severity ; and, besides, 
symptoms of bulbar paralysis made their appearance. Thèse became rather 
rapidly worse, and the patient died, as it were asphyxiated, Peb. 7th, 1871. 

Âutopsi/. — Numerous sclerosed patches found to exist in the brain and spinal 
cord. On account of the ataxic symptoms presented by the patient, the lésions 
of the spinal axis deserve mention. There were sclerosed patclies throughout 
the whole length of the latéral columns. As to the foslerior columns, tliey are 
affected nearly throughout, but, principally, froin the lower extreniity of the 
dorsal région upwards. Pig. 15 represents the lésions observcd on a section 
taken from the upper part of the lumbar région. At this level the posterior 



BULBAR PARALYSIS. 



215 



I hâve réservée! for spécial mention the appearance of some 
symptoms of hnlhar paralysis, because they may, by au abrupt ag- 

columns are completely invaded (6g. 15, c), but especially affected in the mid- 
région. The latéral columns are comparatively less injured. 




PiG. 15. — Représentation of the lésions observed on a section taken from the 
uppermost portion of the lumbar région. The posterior columns are 
invaded throughout their breadth, and the lésion prédominâtes in their 
middle région. 

II. Bez — (Pauline), aged thirty-five, child's nurse, admitted Feb. I7th 
into M. Charcot's wards. To the ordinary symptoms of disseminated sclerosis 
were added, about the niouth of May, dyspnœa and dysphagia. The difficulty 
of déglutition compelled the patient to eat very slowly. Return of food, 
through the nasal orifices, was not observed until near the end. The patient 
died of asphyxia, June i2th, without any râles having been noticed in the 
lungs. 

Âutopsi/. — Sclerosed patch on the chiasma of the optic nerves, invading the 
tractus opticus. Sclerosed patch in the veutricles and in the ceutrum ovale. 
In a section niade a centimètre above the inferior border of the protuberantia 
annularis, on a level with the apparent origin of the trifacial nerve, a large 
and irreguiar patch of sclerosis is found (iig. 16, b' b'). 




FiG. 16. — a, Pneumogastric ; b, small sclerosed patch; Z/', large sclerosed patch. 



216 DUEATION. 

gravation, precipitate the course of events, and induce the fatal 
termination, even before the manifestation of tlie phenomena of the 
final period. Contemporaneously with increased difficulty of utter- 
ance, there appears a difïiculty of déglutition which, though tran- 
sient at first, soon becomes permanent. Then, from time to time, 
paroxysms of dyspnœa show themselves, of less or more gravity, and 
death may supervene during one of thèse fits. I hâve recently 
observed two cases which terminated in this manner. On a post- 
mortem examination it was seen^ in both thèse cases, that a patch of 
sclerosis had invaded the floor of the fourth ventricle, where it 
enveloped the originating nuclei of most of the bulbar nerves.^ 

After the détails which I hâve laid before you, it seems useless to 
undertake the particular description of the différent forms which 
multilocular sclerosis may assume. The ccrelral and spinal forms 
correspond to an incomplète invasion of the nervous centres by the 
sclerosis ; it is, if you like, the disease arrested in its development, 
in its progress either of ascent or of descent. The symptomatic 
séries is, therefore, as it were, curtailed ; but the symptoms, con- 
sidered singly, are not modified. The first, or cérébral, form is very 
rare ; the second, or spinal, is, on the contrary, very fréquent ; but, on 
the whole, the cerehro-spinal form constitutes the normal type, that 
which we most often meet with, inpractice. 

Cerebro-spinal multilocular sclerosis complètes, generally speak- 
ing, its whole évolution in the space of from six to eight years ; ^ 

Auotlier transverse sectiou, corresponding to the middie part of the cor- 
pora olivaria, rcveals another patch of sclerosis (fig. 17 c) apparently in- 
volving tlie pneumogastric (fig. 17 f/). Microscopic examination of the 
îierves showed tlie existence of mimerons fatty degenerated tubes in the 
hypoglossal nerve, and traces of irritation in Sch\iann's sheatli in the pneumo- 
gastric nerve. As to the other organs, and particularly the pharynx, the 
larynx, and the lungs, they were ail healthy. 




c 
Fig. 17. — a, Pneumogastric nerve ; b, h^poglossal nerve; c, sclerosed patch. 

1 It is rather difEcult, at présent, to ascerfaiu the mean duration of dis- 
seminated sclerosis. In a first collection (Bourneville et Guérard, loc. cit., 



PATHOLOGIOAL PHYSIOLOGY. 217 

this establislies another coutrast betweeii it and paralysis agitans, 
the normal duration of wliicli is mucli longer. The spinal form 
usually gives the most lengthy respite ; it may net terminate its 
course for a space of twenty years, or even longer still.^ 

Pathological Physioloc4y; Etiology; Prognosis, and 
Treatment. 

In order to conclude this study, gentlemen, it remains for me to 
discuss the pathological pliysiology, the etiology, and finally the 
therapeutical treatment of multilocular sclerosis of the nervous 
centres. Unfortunately, the facts and documents whicli refer to 
thèse différent subjects ave few in number, and as yet mostly im- 
perfect, so that I shaîl be compelied to confine myself to a few sum- 
mary observations. 

A. The cause of the very singular mode of arrangement under which 
the sclerosed islets are distributed in différent parts of the central ner- 
vous System, is, at présent, completely unknown to us. Herr Riud- 
fleisch has stated that the starting-point for the formation of sclerosed 
foci résides in the vascular system. According to him, the inflamma- 
tion of the walls of the smaller vessels, always to be met with in the 
centre of foci during the process of formation, would be the initial 
fact ; from this central point the irritation is propagated to the reti- 
culum of the neurogha, wlience it radiâtes in ail directions. It is 
évident, however, that this explanation only sets the difhculty a little 
farther back. Besides, this prédominant part accorded to vessels in 
the évolution of the morbid process is anything but demonstrated. 
I am even very much disposed to believe, judging from my own 

p. 148), comprising seventcen cases, we found a mean of from eight to ten 
years. In another, including thirteeu uew cases, we found a mean of seven 
and a half years. The minimum of the duration of the disease was one year 
(case of M. Malherbe, in ' Journal de Médecine de l'Ouest,' 1870, p. 168, and 
Buschwald, " Ueber Multiple Sklerose des Hirns und Ruckenmarks," in 
' Deutsches Archiv fiir Klin. Medicin,' c. x, fas. iv und v, p. 478, 1872). The 
maximum is from sixteen to seventeen years. (B.) 

* lu three cases of disseminated sclerosis, with prédominance of lésions of 
the posterior columns, the disease lasted fourteen, twenty-one, and twenty- 
eight years. (Bourneville, ' Nouvelle étude sur quelques points de la sclérose 
en plaques disséminées,' 1869.) 

- Eindfleisch, " Histol. Détail zu der Grauen Degeneratiou von Gehirn und 
Ruckenmarks" (' Virchow's Archiv,' 1863, t. xxvi, p. 474). 



218 PATHOLOGICAL PHYSIOLOGY. 

observations, tliat tlie altérations of vascular tissue and those of the 
recticulum advance side by side in parallel lines, without acting re- 
ciprocally on each other. Be this as it may, the question arises 
whether, if the position of the sclerosed islets, in the différent por- 
tions of the nervous system, be given^wecan deduce therefrom the 
production of phenomena which, in their totality, constitute the 
symptomatology of disseminated sclerosis ? This is, at least to some 
extent, possible. We hâve already shown you that the motor inco- 
ordination, the loss of sensé of position, and the fulgurant pains 
which are found in a certain number of cases, may, in such cases, be 
attributed to the scierons invasion of the posterior columns of the 
cord for a certain altitude. On the other hand, the customary pré- 
dominance of sclerosed patches along the course of the antero-lateral 
columns accounts, as I shall soon demonstrate to you, for the almost 
constant existence of the paresis or of the paralysis of the limbs, which 
is sooner or later folio wed by permanent contracture. The nystag- 
mus and the difficulty of enunci'ation are correlated with the habi- 
tuai localisation of nodules in the substance of the protuberantia 
annularis and the bulbus rachidicus. But there are a large num- 
ber of other symptoms, the interprétation of which présents much 
greater difficulty. Such, for instance, is the peculiar tremor 
which is manifested during certain attitudes of the body, and in the 
exécution of intentional movements. I hâve expressed the opinion 
that the long persistence of the axis-cylinders, deprived of medullary 
sheathing, in the midst of the foci of sclerosis, probably plays an im- 
portant part hère. The transmission of voluntary impulses would 
still proceed by means of the denuded axis-cylinders, but it would 
be carried on irregularly, in a broken or jerky manner, and would 
thus produce the oscillations which disturb the due exécution of 
voluntary movements. 

This résistance of the axis-cyhnders is certainly not a phenomenon 
exclusively pertaining to multilocular induration; but it is hère mani- 
fested in a more marked manner than in other forms of sclerosis of 
the nervous centres. It may also be quoted, I think, to account for 
the slowness with which the paretic symptoms advance in dis- 
seminated sclerosis, and for the long space of time which elapses 
before they give place to complète paralysis and permanent con- 
tracture. 

B. What is known in référence to the conditions that préside over 
the development of disseminated sclerosis comcs to very little. It 



CAUSES. 21^ 

seems, however, to be established at présent, tliat. the disease is far 
more common in females than in maies. Thus, of ail the instances 
which I collected in my first treatise, only three or four related 
to inen. The cases which hâve since been published hâve uot 
modilied this resuit in any perceptible manner. Adding to the 
eighteen cases which are mentioned in the monograph of MM. 
Bourneville and Guérard, sixteen new cases, we get a total of thirty- 
four cases, of which nine relate to maies, and twenty-five to 
females. 

Judging from the same records, it follows that this is a disease of 
youth, or of the first half of adult âge. It has been observed in 
patients aged fourteen, fifteen, and seventeen years,i but it seems 
most frequently to set in between twenty-five and thirty years. It 
rarely makes its appearance after thirty. On the other hand, forty 
years seera to be the ultimate limit of life for patients affected by 
disseminated sclerosis. 

With respect to the influence of hereditary prédisposition, we 
hâve only one case to mention in which it seems to hâve played a 
certain part. This example has been communicated to us by Dr. 
Duchenne (de Boulogne). 

In the pathological antécédents of the patients themselves we 
generally find nothing but vague indicia. Hysteria was présent in 
some cases, but in most we only lind mention made of ill-determined 
neuropathies, occasional hemicrania, or neuralgias." 

^ In a work by M. Leubé ("Ueber multiple inselformig Sklerose der 
Gehirns und Ruckenmarks," in ' Deutsches Archiv,' 8 Bd., i heft, 1870, p. 
14) we find the record of the case of a child who preseuted the first symptoras 
of disseminated sclerosis at the âge of seven years. She died aged fourteen 
years and six raonths. Summary : slight nystagmus ; right facial paralysis ; 
marked ataxia of the extremities, especially on the left sida ; tremor of the 
head ; difiiculty of utterance ; atrophy of the legs. Auiopsj/ : sclerosis of the 
pons Varolii and annexes, alniost gênerai on the right, disseminated on the left. 
The cerebrum and cerebellum présent, in their cortical layers, a double degene- 
ration, whitish-yeliow, or steel-grey, partly diffused, partly disseminated in 
patches. In the cord, and principally in the medulla oblongata, the sclerosis 
occupies, firstly, the posterior columns, next the latéral columns, and finally 
the anterior columns. (B.) 

" There is, however, an etiological cause which deserves mention, uamely, 
the influence of certain acute diseases on the development of sclerosis. The 
foUowing facts are given in support of this assertion : 

1°. In a case given by Erbstein (' Deutsche Archiv fiir Klinische Medicin,' 
t. X, fasc. 6, p. 596) disseminated sclerosis set in during convalescence from 



'220 OCCASIONAL CAUSES, 

Amongst occasïonal causes, we frequently fiud mention made of 
tlie prolonged action of moist cold.^ In one case, the first symptoms 
are alleged to hâve appeared a short time after a fall. 

But the circumstances most commonly assigned as causes of 
•this disease, by patients, appertain to the moral order — long- 
continued grief or vexation, such, for instance, as may arise from 
ilhcit pregnancy, or the disagreeable annoyances and carking cares 
which a more or less false social position entails. This is often the 
case as regards certain female teachers. Having said so much with 
Tcspect to women," the question of maie sufferers arises. Thèse are, 
for the most part, persons who hâve lost caste, and who, thrown 
ont of the gênerai current, and too impressionable, are ill-provided 
with the means of maintaining what, in Darwin^s theory, is called 
the ^'struggle for life." In short, the etiology is a somewhat 
irite one, such as may be met with again, as it were, at the begin- 
ning of ail the chronic diseases of the central nervous system. 

C. The proffnosis has hitherto been of the gloomiest. Shall it be 

typboid fever. The patient, theu, sufFered fi"om debility of the lower ex- 
tremities, and a difficulty of enunciation ; the words were scanded, and the 
pronunciation was somewhat indistinct and monotonous. 

2°. A patient in M. Charcot's charge, Nie — (Julie) noticed a certain degree 
of weakness in her lower limbs, ou recovering from an attack of choiera. Some 
short time after, she had an attack of typhoid fever, after which the feebleness of 
her limbs augmeuted in a slow but contiuuous manner, to such an extent that 
she was soon obiiged to use a caue. {A. Joffroy, ' Mémoires de la Société 
-de Biologie,' 1869, p. 146.) 

3°. In the case, recorded by MM. Fontaine and Liouville, it is mentioned 
that the first signs of sclerosis were preceded by copions bilious vomitings, 
wliich lasted from ten to fifteen days. (H. Liouville, in ' Mémoires de la 
Société de Biologie,' 1869, p. 107.) 

4°. Fiually, we will mention the case of a woman named Dr — (Hortense), 
in whom the first symptoms of disseminated sclerosis appeared soon after she 
had had a severe attack of smallpox. (B.) 

^ A patient, according to Herr Baerwiukel, experienced a difficulty in exe- 
-<;uting movements with the right leg, three days after having fallen into water. 
The action of moist cold has a reality in this case, because the patient allowed 
liis wetclothes to dry upon liim. (B.) 

^ The ' Lancct ' (1873, vol. i, p. 236) has published the summary of a case of 
disseminated sclerosis recorded by Dr. Moxon, at Guy's Hospital, in which 
we Cnd the following causes mentioned — a, fel)rilc disease, accompanied bj 
diarrhœa, which lasted for scveral wecks ; i, a violent moral émotion experienced 
% the patient ou seeing her husband in bed with another female. (B.) 



PROGNOSIS. TEEATMENT. 221 

always tlius ? It is to be hoped tliat^ wlien tlie disease lias becomc 
better known^ the physician will learu liow to take advantage of 
that spontaneous tendency to remission wbich bas been noticed in a 
great number of cases. Nor must it be overlooked tliat, at the 
présent time, the real nature of the disease is not recognised until 
the lésions hâve become well marked, and are consequently but little 
amenable to the influence of therapeutic agencies. 

D. After what précèdes, need I detain you long over the ques- 
tion of treatment ? The time bas not yet corne vvhen such a subject 
can be seriously considered. I can only tell you of some experi- 
ments which hâve been tried, the results of which, unfortunately, 
hâve not been very encouraging, 

Chloride of gold and phosphate of zinc appear to hâve rather 
exasperated than improved the syinptoms. Strychnine bas some- 
times caused cessation of the tremor, but its influence bas always 
been transient. The same is to be said of nitrate of silver. In 
several cases, which I hâve noted, it seems to hâve had a very favor- 
able influence over the tremor aud the paresis of the limbs, but this 
influence was not of long duration. 

The exhibition of this drug is formally contra-indicated by 
the existence of permanent contracture, and especially of spinal 
epilepsy; its employment, in such cases, would almost certainly 
hâve the effect of exasperating thèse symptoms. The hydropathic 
treatment seems to hâve produced a temporary amendment in one 
case; in another, on the contrary, it completely failed. 

Arsenic, belladonna, ergot of rye, and bromide of potassium bave 
been likewise administered, in disseminated sclerosis, without auy 
marked benefit. The same may be said of faradisation and of gal- 
vanism. As regards the employment of the continued current, 
however, farther experiments are required before we can form a 
definite judgment.^ 

- Other drugs hâve also been employed, without better success than resulted 
from the use of those euumerated by M. Charcot. Such are, phosphorised oil, 
iodide of phosphetjlamine, and Calabar Bean. Since the publication of the 
first édition of thèse Lectures several works or observations concerning dis- 
seminated sclerosis bave appeared. As they only confirm the descriptions 
traced by M. Charcot, we confine ourselves to a simple catalogue. i°. Timal, 
" Etude sur quelques complications de la sclérose eu plaques disséminées." 
Thèse de Paris, 1873. 2° and 3°. H. Schûle, "Beitrag zur raultiplen Sklerose 
des Gehirns uud Ruckenraarks," in ' Deutsches Archiv fur Klinische Medicin,' 
1870, Bd. vii, p. 259. " Weiterer Beitrag zur Hirn Ruckenmarks Sklerose " 



222 TREATMENT. 

(ibid., 1871, Bd. viii, p. 223). Baldwin, "A Case ofDiffused Cérébral Sclerosis" 
('Journal of Mental Science,' 1873, July, p. 304). 5°. Moxon, "Two Cases 
of insular Sclerosis of tlie Brain and Spinal Cord" ('The Lancet,' vol. i, 
p. 471, 609, 1875). 6°. Euzzard, " Disseniinated Cerebro-Spinal Sclerosis," 
(ibid., vol. i, p. 45). 7°- Moxon, " Eiglit, Cases of Insular Sclerosis of the 
Brain and Spinal Cord" (' Guy's Hospital Reports/ 3rd séries, t. xxi, London, 
1875). 



PART THIRD. 



HYSTERIA.— HYSTERO-EPILEPSY. 



LECTUEE IX. 

HYSTERICAL ISCHUMA. 

""SuMMARY, — Introduction. Hystencal iscJmria. Différences ivîdch 
divide itfrom oligiiria. General considérations. Supplementary 
vomiting. Historical sketch. Causes which hâve throum doubt 
on tJie existence of hysterical iscJinria. Distinction hetvjeen 
calculons isclmria and hysterical ischuria. 

Case. Hysterical paralysis and contracture. Complète 
hemianœsthesia. Hemiopia and achromatopsia. Ovarian 
hyper œsihesia. Rétention of urine. Tympanïtis. Conmdsive 
seizures ; trismits. Manifestation of hystericalischuria. Pré- 
cautions taken io guard against error. Complète amiria. 
JJrœmic vomiting. Relation of the quantity of urine excreted to 
the vomited matter. Chemical analysis of vomited matter, 
nrine, and blood. Suspension of phenomena. 

Re-appearance of hysterical ischuria. New results ofchemical 
analyses. 

Serious nature of common anuria and of expérimental 
amiria. Limit of the duration of accidents compatible with life. 
Influence of the évacuation of even a minute quantity of urine. 
Rapid appearance of symptoms in calculous ischuria ; their 
tardiness in hysterical ischuria. Innocuousness of sympttoms 
in direct ratio with the quantity of urine secreied. Résistance 
to inanition in hysteria. 

Mechanism of hysterical ischuria. Imperfect supply of 
information in relation to this subject. 

Gentlemen, — It is my intention to résume and to complète, in 
our conférences of the présent year, the séries of studies which we 
nndertook two years ago, and which were rudely interrupted by the 
painful events with which you are acquainted. 

At the epoch when we were forced to separate^ I was endeavouring, 

15 



226 PRELIMINART EEMAEKS. 

by thé application of preliminary researclies concerning trophtc 
disorders dépendent on nervous influence, to show, as you may 
remember, that many affections of the muscular System, hitlierto 
attributed to peripheral causes, are in reality subordinate to lésions 
occupying well-defined régions of the grey matter of the spinal 
cord. 

This group of muscular affections, which I propose to call spinal 
myopathies, or myopathies of spinal origin, shall occupy our attention 
in a very spécial manner. I will also revert to the interesting group 
of scierons affections of the spinal cord, and, amongst others, to 
that sclerosis which détermines the symptomatic phenomena of pro- 
gressive locomotor ataxia.^ The subject is far from being exhausted, 
and I shall hâve occasion to point out, in référence to thèse dis- 
eases, many facts which are new, or which were previously but 
imperfectly known, and which the investigations conducted in this 
hospital hâve made clear. 

1 intend also to treat of the severalkinds oî paraplegia^^ produced 
by slow compression of the cord, oîchronic spinal meningitis, and of 
some diseases of the brain and spinal cord, the study of which bas 
been hitherto greatly neglected. 

But before returning with you, gentlemen, to thèse arduous 
questions, I cannot resist the désire of taking immédiate advantage 
of a number of very remarkable cases of hysteria which are, at pré- 
sent, assembled in our wards. It is requisite to lay hold, without 
delay, on this fortunate circumstance, for, on account of the mobile 
character proper to the great neurosis I hâve named, the symptoms 
which are, to-day, manifest in a high development may, on the 
morrow, bave completely vanished. 

Among thèse cases there is one especially deserving of attention, 
which shall form tlie object of our first conférence ; it is, if I do 
uot deceive myself, a legitimate example of a rare, an extremely 
rare affection, the very existence of which is disputed by most 
physicians. 

ïhe study of exceptional cases, gentlemen, is not to be disdained. 
They are not always mère baits for vain curiosity. Many a time, 
indeed, they supply the solution of difficult problems. In that 
respect they may be compared to those lost or erratic species which 

' See " Leçons sur les Maladies du Système Nerveux," 2e série, fascicules 
2 et 3. 

2 Charcot, loc. cit., 2e série, fasc. i. 



ISCHURIA AND OLIGUEIA. 227 

the iiaturalist anxiously seeks for, because they show the mode of 
transition between différent zoological families, or enable bim to 
unravel some knotty point of comparative anatomy or pbysiology. 

Hystencal tsclmna is the affection to which I allude. At the 
outset, I should explain to y ou the technical meaning of this désigna- 
tion, which some of you now, probably, hear mentioned for the first 
time. 

A. Ischuria, stoppage of urine, — thèse terms, technically 
considered, signify the same thing. Hysterical ischuria bas, bow- 
ever, a more restricted meaning. 

There is no question hère of a simple rétention of urine in the 
bladder — tbat is a hackneyed fact in hysteria. You know that verj 
commonly the use of the cathéter, in such cases, may need to be 
continued for months, nay years; but then the urine withdrawa 
from the bladder is abundant in quantity, or, at ail events, the 
amount is not far removed from the normal standard. 

In the ischuria of hysterical patients the obstruction is situated 
neither in the urethra nor in the bladder. It lies higher up, either 
in the ureters or in the kidueys themselves, or still more remotely. 
But that is a point which yet remains to be decided. The principal 
fact is this, namely, the quantity of urine secreted in the twenty- 
four hours and withdrawn by the cathéter (for hysterical ischuria is 
almost always complicated by urethral rétention), this quantity, î 
repeat, is remarkably under the normal amount. It is even frequentij 
reduced to zéro, and during several days there is, in fact, absolute 
suppression of urine. 

B. It is proper, in this relation, to establish spécifie catégories» 
Oligurïa, or even total suppression of urine, may be only a transienf, 
phenomenon in hysterical cases, and one, as Dr. Laycock bas rightiy 
remarked, which may frequently occur unnoticed. Thus, we oc- 
casionally observe in hysterical patients, especially at the catameniai 
periods, a complète suppression of urine which does not last more thaa 
from twenty-four to thirty-six hours. There may, perhaps, be some 
feeling of uneasiness experienced, and the puise may be quickened; 
but, after a short time, a few spoonfuls of urine are expelled and the 
normal state is restored.^ 

The cases upon which I would fix your attention are very differenè 
from those to which I bave just referred. They présent hysterieai 

^ Laycock, 'A Treatise on the Nervous Diseases of Women,' Loîîdoa, 
1840, p. 229. 



228 EXPERIMENTS. 

ischuria at its maximum of development wlien it lias assumed tlie 
cliaracter of a permanent symptom. During tlie lapse of several 
successive days, of weeks, and of montlis^ the quantity of urine 
rendered, in the twenty-four hours, may be quite iusignificant 
in amount or almost nil. Occasionally even, tliere is complète sup- 
presslon of urine during a séries of several days. 

Wlien matters take this turn tliere is superadded, as it were of 
necessity, anotlier plienomenon whicli may be called the complément 
of the first ; I mean repeated vomitings, whicli take place daily and 
even several times a day, so long as the ischuria continues. The 
ejected matter occasionally, it is said, présents the appearance and 
exhales the odour of urine. It is certain tliat chemical analysis 
has, in two or three cases, detected in this vomited matter the présence 
of a certain quantity of nrea. 

To sum up, gentlemen, hysterical ischuria offers, in the human 
species, a more or less exact reproduction of some of the symptoms 
observed in animais^ in cases of nephrotomy or of oblitération of 
the ureters by ligature. 

The experiments of Prévost and Dumas, and particularly those of 
MM. Claude Bernard and Barreswill, teach us, as you are aware, 
that, after thèse mutilations, a vicarious élimination is effected by 
means of the intestine. In the matter so eliminated, there hâve been 
found, according to some observers, carbonate of ammonia resulting 
from the décomposition of the urea (Claude Bernard), and, according 
to others, ^lrea itself has been detected (Munck). Howèver this may 
be, so long as the élimination is effected, the animais seem to suffer 
little inconvenience, and it is only when they become enfeebled and 
the supplementary excrétion ceases, that grave phenomena présent 
themselves which soon occasion dcath. 

You perceive the analogies and, at the saine glance, are struck by 
the contrast. Cérébral symptoms inevitably occur,at a given moment, 
in cases of experiments practised on animais, whilst in hysterica 
patients the alternation between rénal excrétion and vicarious ex- 
crétion may continue for weeks and months, without any visible 
disturbance of the gênerai health ever resulting. But I do not 
wish at présent to dclay upon this point, to which I will hereafter 
rcturn. 



HISTOEICAL SKETCH. 229 



II. 



Suclij gentlemen, is hysterical ischuria, at least in its essential 
character, according to the few authors who hâve acknowledged its 
existence ; for, T repeat, the reality of this disorder has been dis- 
puted. You will not find it mentioned in any of the récent works 
or articles on hysteria, not even in the most complète and most 
justly esteemed amongst them. There is no mention whatever of 
it, for instance, in the great work of M. Briquet. In short, of con- 
temporary authors, Dr. T. Laycock, Professor in the University of 
Edinburgh, is, perhaps, the only pathologist who, in his writings, 
has given domicile to hysterical ischuria. After devoting to this 
question a séries of articles,^ in which he relates two original cases, 
Dr. Laycock returns to the subject in his well-known work on the 
'Nervous Diseases of Women^ (1840). Everywhere else, if hys- 
terical ischuria be mentioned, it receives but a passing notice by 
way of référence, and not without an ironical allusion to those 
observers who bave been so simple as to gravely accept this 
"pretended symptom." 

On the other hand, it is not uninteresting to note that the physio- 
logists, Haller first, then Carpenter, and Claude Bernard (thèse, 
however, without affirming anything), hâve shown themselves, in 
référence to this subject, far less sceptical than were such 
physicians as Prout and H. Willis. 

Until recently , I shared the almost gênerai incredulity which pre~ 
vailed in référence to hysterical ischuria, being, indeed, prepossessed 
by the teachings of my master. Rayer, who never lost an opportunity 
of expatiating lengthily on the varions déceptions of which hys- 
terical patients are guilty. And he did not hesitate to confess that 
he, who was himself a sagacious and very keen observer, had often 
nearly fallen a victim to their strategy. -Latterly, my opinions 
hâve been somewhat modified in présence of the case to which I shall 
shortly invite your attention. 

Before placing you in a position to judge for yourselves whether 
or not my conversion has been too précipitât e, let us investigate the 
principal reasons why certain authors pass over hysterical ischuria in 
silence, whilst others only mention its name in order to relegate it 
amongst the number of chimseras. 

' ' The Edinburgh Médical and Surgical Journal,' 1838. 



230 SIMULATION. 

1°. In the first place, it must be remarked that liysterical iscliuria 
îs a rare phenomenon, at least in its very marked form, for it is 
possible, as we bave already said, that sligbt cases many often be 
overlooked. 

a. Thus, Dr. Laycock, who searcbed everywhere, could not col- 
îect more than twenty-seven cases, only two of whicb came under 
liis own observation. 

b. Let us add that a somewhat rigorous criticism would, most 
eertainly, reduce this number still further. Most of the cases are 
old ones, dating as they do from the sixteenth and seventeentli cen- 
turies, and they do not offer those notes of exactness which we re~ 
quire at the présent period. Others are manifest impostures. Who 
could be got to believe, for instance, that a woman could, intwenty- 
four hours, render through the ear half a gallon of a fluid which, 
on being analysed, was found to contain urea ? And that is not ail. 
This very woman is stated to hâve, at the same time, ejected a similar 
fluid by the navel — " spirted out" is the term employed by the author 
of the report. Yet ail thèse détails, and many others besides, are 
recorded, with the utmost gravity, in the ' American Journal of 
Médical Sciences' (1828). Permit me, I beg of you, to pass in 
silence over the name of the physician who made himself re- 
sponsible for this case. 

3°. Tliis leads me to say a word on simulation. You will meet 
with it at every step in the history of hysteria, and one finds him- 
self sometimes admiring the amazing craft, sagacity, and persévér- 
ance which women, under the influence of this great neurosis, will 
put in play for the purposes of déception — especially when a 
physician is to be the victim. As to the case in point, however, it 
doesnotseemto me demonstrated that the erratic parnria of hysteria 
has ever been wholly simulated and, as it were, created by thèse 
patients. On the other hand, it is incontestable that, in a multitude 
of cases, they bave taken pleasure in distorting, by exaggerations, 
the principal circumstances of their disorder, in order to make them 
appear extraordinary and wondcrful. 

The foUowing is the gênerai séquence of things. Anuria or 
ischuria, with vomiting, exists alone for a certain time, and the 
phenomenon is consequently reduced to its simplest form. Soon, 
however (especially if the syraptoms seem to excite the interest 
and curiosity of the physicians), pure urine will be thrown up in 
considérable quantity ; it will issue from the ears, the navel, the 



CALCULOUS OBLITERATION OF UEETERS. 231 

eyes, and even from the uose, as we read in tlie account given 
by the American journal. Einally, if the wonder of the observers 
be extremely excited, there will probably be vomiting of fsecal 
matters. 

Amongst this class of cases, that which in France attained most 
notoriety was the case of a patient named Joséphine Roulier, who, 
for over fifteen months, was a prominent personage in the clinical 
wards of Professor Leroux. This happened about the year 1810. 
The patient had first presented the symptoms of simple ischuria 
with erratic paruria. Nysten^ who records the case, analysed the 
vomited matters and detected the présence of urea. Shortly after, 
there came a ilow of urine from the navel, the ears, the eyes, the 
nipples, and finally an évacuation of fsecal matters from the mouth. 
You see, gentlemen, that the séquence is always the same, whatever 
be the country or century in which the observations were taken. 
The fraud was discovered by Boyer. It was found that the 
use of a strait waistcoat caused cessation of the extraordinary 
phenomena, and some hard fsecal pellets were discovered, stored 
away in the patient's bed ready for use. Unfortunately, Nysten 
hadjust published his 'Recherches de Physiologie et de Chimie 
Pathologiques.^ It was necessary to make honorable réparation. A 
note was accordingly inserted in the ' Journal Général de Médecine,' 
and another was appended to some copies of Nysten's book. 

In présence of thèse facts, must we conclude that ail is im- 
posture in hysterical ischuria ? I do not believe it, gentlemen, 
and I hope you will share my opinion when you shall hâve been 
made acquaiuted with ail the peculiarities of my patientas history. 

There is another circumstance which is, also, well adapted to 
throw an unfavorable shadow upon accounts of cases of hysterical 
ischuria. It is this : — apart from hysteria, suppression of urine 
if it but persist beyond a few days, say three, or four, or five, is 
an exceedingly serions sym-ptom, which almost necessarily termi- 
nâtes in death. 

Leaving aside those cases of anuria depending on an acute or 
chronic form of Bright's disease, which are too complex for admis- 
sion hère, I will sélect as typical the calculons ohllteratlon of the 
2bTeters, supervening in persons previously in good health. In 
such cases, it lias happened that sometimes one kidney lias been 
reduced, through antécédent disease, to a fibrous husk filled with 
cysts, and consequently rendered incapable of fulfilling its function 



233 EXCEPTIONAL CASES. 

of eliminating urine ; sometimes, but more rarely, botli ureters are 
obliterated at once. It little matters, in so far as our object is con- 
cerued, whether this oblitération be accompanied or not by the 
pains of nephritic colic. Now, Halford,^ Abercrombie, and ail 
authors who hâve studied thèse cases agrée in stating that if anuria 
persist beyond four or five days, comatose symptoms, with or 
without convulsions, inevitably appear and are soon foUowed by 
death. 

Life is prolonged a little if even a small quantity of urine can, 
be rendered, but the final resuit is always the same. 

There is, however, the chapter of exceptions, which we should the 
less neglect, because we are taking advantage of some of its con- 
tents. The folio wing exceptional cases are in the books : 

1°. In the case reported by Dr. Laing, of Pochabers, quoted by 
Robert Willis,^ anuria lasted ten days, and recovery took place. 

2°. In the case of a patient of Dr. W. Eoberts (of Manchester) 
somnolence did not supervene until the eighth day, four days 
before death. '^ 

3°. The most remarkable example within my knowledge of 
prolongation of life, under such circumstances, is that which was 
recently published by Mr. Paget, in the 'Transactions of the 
Clinical Society of London.'^ Although there was absolute anuria, 
the comatose symptoms did not présent themselves until the four- 
teenth day. On the fifteentli the patient passed a certain quantity 
of urine. There was, however, aggravation of symptoms, and the 
fatal termination took place on the twenty-third day. 

However it be, you observe that, just as happened in the case of 
experiments made on animais, hère also the contrast is striking 
between calculous iscJmria, which almost certainly kills the patient, 
and lysterïcal iscJmria, which allows the patient to survive during 
long months without seriously disturbing the gênerai health. We 
are thus placed in présence of a grave problem. Is it really in- 
soluble ? This is a question which we purpose investigating 
at a future opportunity. 

' ' Médical Transactions/ published by the Collège of Phjsicians, t. vi, 
1820. 
- "Urinary Diseases," London, 1838, p. 35. 

^ Sec account of this patient in Bournevillc, " Études Clin, et Therm.," &c.,, 
p. 175; and Roberts in 'Mouvement Médical,' 1871. 

■^ J. Paget, " Case of Suppression of Urine vcry slowly fatal." In 'Trans- 
actions of Clinical bociety of Loudon,' t. ii, 1869. 



CLINiCAL CASE. 233- 



III. 



It is full time, gentlemen^ that we sliould enter upon a study of 
the clinical case wliich constitutes tlie basis of our conférence. In 
the first place we must examine the groundwork to whicli our 
observations relate ; andj witli this object in view, the best thing I 
can do is to show you the patient, and to point ont before you the 
symptoms that are actually in existence, amongst which you will 
discern the signs of an intense, inveterate hysteria, marked by a 
characteristic reunion qî permanent sj/mptorns. 

Justine Etch — , born in the department of the Basses-Pyrenees, 
is forty years of âge. She followed the profession of hospital nurse. 
She was admitted into this hospital of La Salpêtrière in 1869, so 
that we can trace the progress of her malady during four years. 

What is her présent condition ? That which first strikes you in 
référence to her is the vast contracture which affects the upper and 
lower limbs on the left side. This contracture, which ceases neither- 
during natural sleep, nor during sleep induced by chloroform, unless 
the influence of this agent be pushed to an extrême, suddenly 
developed itself on the 2oth March, 1870, after a severe hysterical 
fit. We should mention, however, that the arm had previously 
been quite paralysed, but flaccid, whilst the corresponding lower ex- 
tremity was already rigid. The latter circumstance, together with 
the rapidity with which the contracture made its appearance, autho- 
rised us in declaring, at the time, that no circumscribed cérébral 
lésion had occurred to cause the phenomena displayed. 

Another distinguishing feature which we find, in this patient, is 
the existence of complète hemianœsthesia, which occupies both 
the contractured limbs and the left half of the face and body. Not 
only does this ansesthesia affect the external tégument, but it also 
extends to those portions of the mucous membrane and of the organs 
of sensé situated on the left half of the body. Thus, witli respect to 
the faculty of sight, we note hère the existence of liemiopia and of 
achromatopsïa ; this phenomenon was observed by Dr. Galezowski, 
under similar circumstances, and is one to which we shall again 
return. 

When developed to this extent, hemiansesthesia gives us a group 
of symptoms which are almost spécifie; I say almost, but not aiso- 
lutet//, spécifie, because we shall soon see that even coarse cerebraV 



234 OVAEIAN HYPER^STHESIA. 

lésions, confined to certain portions of the encephalon, may at 
least partially reproduce them. 

One other verj important symptom is presented by Justine 
Etch — . Tliis is a pain seated just above the left groin. M. 
Briquet bas given this the name of ccdïalgia, and regards it as 
residing in the muscles. For my part, agreeing on this point with 
Négrier, Schutzenberger, and Piorry, I believe its source to be 
the ovary. Whatever be its exact seat, this pain, which I shall 
term ovarian hjperœsthesia, is to a certain extent pathognomonic. 
Pressure, whicli exaspérâtes it, causes irradiated sensations of a 
perfectly spécial character. Thèse sensations, springing from the 
ovarian région, successively attain: i°. the epigastriuni ; 3°. 
the neck or throat, — manifesting themselves in thèse régions by a 
more or less considérable oppression, the well-known sensation of a 
bail or globe {glohus hydericui), — 3°. the head, where the irradia- 
tion is characterised by buzzing and whistling in the left ear, by 
cephalalgia with throbbings, which the patient compares to so many 
hammer-strokes on the left temple, and finally to an obnubilation 
of sightin the corresponding eye. I confine rayself, for the moment, 
to a simple enumeration of thèse phenomena, which require a more 
minute description. 

Among the other symptoms, I must not forget to mention 
rétention of urine and tj/nijMnitis, which also are permanent phe- 
nomena in this case. Pinally, this woman is subject to spécial 
seizures, which are sometimes tetaniform, sometimes epileptiform, 
but which occasionally resemble the common hysterical type. Thus, 
this morning, you can perceive a symptom which dates from a 
seizure that took place two days ago. I refer to the trismus which 
lias proved au obstacle to natural alimentation since that period. 

IV. 

The patient may now retire. We shall be able to relate more fully, 
in her absence, the other peculiarities of her history. It is a real 
Odyssey. Hence I shall bc often compelled to abridge it, whilst 
taking care, however, to indicate the séquence of the accidents. 

The first fit of convulsions occurred in 1855. ^^bat the circum- 
stances were we do not know. The account she gives is quite a ro- 
mance, a case of râpe (?), — a tangled story, the accuracy of which it is 
diilicult to ascertain. It is, however, certain that the seizure in 
question was apparently one of extrême violence; the patient fell 



CLINICAL CASE. 235 

into the fire, burning lier face, aud you hâve noticed tlie indelible 
stiginata wliich were caused by that accident. Datiiig from tliat 
period, the fits hâve continued to show themselves, from time to time, 
with the same characters, but rather rarely, — about twice or thrice a 
year. 

Teu years later, reteutiou of urine appears. The patient bas an 
attack of hemiplegia with flaccidity of the left side, after one of her 
usual fits, and is brought into M. Lasègue^s wards. 

Admitted the same year (1S69) to La Salpêtrière, we note— 1°. 
The existence of left hemiplegia, with flaccidity of the upper and con- 
tracture of the lower extremity. 2°. Hemiansesthesia and achroma- 
topsia of the same side. The symptoms then presented by Justine 
Etch — are detailed in the thèses of MM. Hélot and Berger. 

In 1870 afFairs remain much in the same state, ouly that a uew 
fit has been foUowed by contracture of the left arm ; and, at that time, 
(in 1870) I showed you this patient as supplyingan example of the 
hémiplégie form of hysterical contracture.^ 

In the month of March, 1 871, a fit is folio wed by flaccid hemi- 
plegia of the righiside. In a month's time, the flaccidity is replaced 
by contracture. In April, then, we had under our eyes as intense a 
contracture of the four extremities as it is possible to conceive ; the 
contracture was absolute, persisting uight and day, during sleeping 
and waking, and even resisting the influence of sleep induced by 
chloroform, or only giving way before the highest dose. 

This woman was, therefore, you perceive, condemned to complète 
confinement in bed ; it was impossible for her to use her limbs. 
Better conditions could not be desired to render surveillance easy. 
I took care, moreover, to place near her two devoted patients, bed- 
ridden like herself, who were ready to reveal ail if they should dis- 
cover any trickery. I had there the best possible police, that of 
women over women, for you are aware that if women enter 
into any plot among themselves they very seldom succeed. This 
statement will, I believe, be sufiÊcient to convince you, gentlemen, 
that, during this first period, simulation was impossible. My friends 
Professors Brown-Séquard and Eouget, who saw the patient at 
this epoch, declared themselves satisfied with ail the précautions 
taken. 

* The lecture referred to, wliicli will be found further on, was first published 
in the 'Revue Photographique des Hôpitaux de Paris,' i87i,p. 103. Plate 
XXV of the ' Revue ' gives a portrait of this patient. 



236 CLINIOAL CASE. 

It now remains for us to sliovv you liow^ in the midst of con- 
ditions so favorable to regular inspection, the phenomenon of 
iscburia was produced. 

The ischuria cominenced in the month of April, 1871. Before 
this a woman employed in the hospital, who catheterised the patient, 
several times a day, had ah'eady noticed that the quantity of urine 
withdrawn was occasionally very minute, whilst at other times 
none was yielded for two or three days, or even more, nor were the 
sheets ever moistened. 

In addition to thèse symptoras, which persisted during May and 
June, vomiting soon appeared, and proceeded without effort or 
straining. I pretended, from the outset, to be nowise surprised at 
thèse occurrences, confining myself to directing that the patient 
should be discreetly watched both night and day. She was never, 
however, for a moment detected in any déception. 

Cast your eyes, I pray you, on thèse diagrams (Plates V, YI, and 
YII) which I place before you, and you can follow, in the several 
phases of their évolution, the accidents which hâve presented them- 
selves to our observation. The fabulation begins on the i6th July, 
1871, when I caused the urines and vomited matter to be collected 
separately, day by day. It ceased in October of the same year 
(Plates V, VI). 

Prom the i6th to the 3ist of July the quantity of vomited matter 
varied from 500 to 1750 centilitres, the daily average being one 
litre (or if pints nearly). The quantity of urine varied between 
o and 5 grammes; the average in the twenty-four hours being 2*50 
grammes (or about 38^ grains). During this period, there was 
absolute ischuria every second day. 

In August, the average amouut of urine rendered was 3 grammes 
(or 46 ] grains) ; that of vomited matter was one litre in the twenty- 
four hours. During the course of this month there was, on several 
occasions, complète auuria, lasting for several days. But, note 
that the total absence of urine never persisted beyond eleven days. 

Prom the i st to the 3oth September, the average amount of 
vomited matter rose to a litre and a half (say sf pints) per day, 
whilst that of the urine rcmained at 2*50 grammes (Plate VI). 

There is one fact brought into promincnce, on examination and 
comparison of the curves rccorded on this table, namely, that the 
curve of the vomiting generally rises when that of tlie urine falls, 
and inversely. Owing to this state of alternate cquilibrium thcrc has 



CLINICAL CASE. 237 

been a tolerably fair balance maintaiued between tlie results of tliese 
two pheuomena. 

What lias been the gênerai condition of the patient, as regards 
bealtli, during tins long period of four mouths which the investigation 
lasted? At no time hâve we remarked any disturbance of the 
gênerai health worth noticing. The alimentation was, as you can 
readily understand, very limited ; the stomacli rejected almost 
immediately, but without fatigue (a characteristic of hysterical 
vomiting justly noted by Dr. H. Salter '), the greater portion of the 
food swallowed by the patient. Yet, notwithstanding thèse adverse 
conditions, nutrition scarcely suffered. This, indeed, is a fact well 
known, apart from anuria, in cases of uncontrollable hysterical 
vomiting. 

I had believed from the outset that the matter vomited by our 
patient must contain urea. The first investigations undertaken witli 
a view to detect its présence were, however, fruitless ; then I requested 
the assistance of M. Gréhant, whose competency in such matters is 
beyond a doubt. He most obligingly placed himself at our disposai. 

Twenty-two cubic centimètres of urine collected on the 2oth of 
October, and representiug the whole amount of urine rendered that 
day, gave, on analysis, 0*179 gramme (nearly 2f grains). On the 
iith October the total vomited matter, amounting to 1460 cubic 
centimètres, gave 3699 grammes (or 26^ grains) of urea. 

In order to détermine if our patieut's blood contained a greater 
proportion of urea than in the normal state, we decided to abstract 
a little of the venous fiuid. In order to accomplish this opération 
it was necessary to induce sleep, on account of the obstacles pre- 
sented by the contraction of the members. The opération having 
been accomplished, M. Gréhant found that in the blood taken 
from Etch — the urea amounted to 0'036 gramme per hundred 
grammes of blood; whiist in that taken for comparative examination 
from a healthy individuel there existed o*o34. gramme per cent. 
You see that the results of the two analyses are (almost) identical. 

Unfortunately for the continuance of our investigations, the 
administration of chloroform had the effect of greatly modifying the 
symptoms which we had been watching with so much interest ; 
incontinence of urine followed, lasting for several days. The 
vomiting, moreover, was suspended soon after, and the urine 
gradually returned to the normal standard, 

1 The ' Laucet,' Nos. i and 2, t. ii, 1868. 



238 VARIATIONS OF HYSTEEICAL ISCHUEIA. 



V. 

Such, gentlemen, are the results of the first séries of studies 
"which decided us to undertake the restoration of hysterical ischuria 
to a place amongst clinicalrealities. The same phenomena, indeed, 
were destined agam to présent themselves, under a less striking 
aspect it may be, but one quite as fuîl of interest. In this second 
phase, no complète anuria occurred, not even temporarily. We 
noted a simple oliguria. The matter vomited was not thrown off 
in such abundance. In a word, if the accidents had been a little 
less marked, and if we had not been enlightened by the foregoing 
observation, it is incontestable that the supplemental élimination 
of urea might hâve altogether escaped attention. 

Let us briefly observe what took place during this second 
period. After a more or less complète remission of symptoms, 
rétention of urine was the first to make its appearance again. 
This was in January. The following month, after a fit, we noted 
alternations of oliguria and of polyuria, when tliere were two litres 
(or 3 e pints) ipasseà j)er diem. In March, the urinary sécrétion 
diminished to a decided extent; and, on the i8th of the same 
month, vomiting again showed itself. From that date, until the 
3ist of March, the daily average of vomited matter amounted to 
500 grammes. In April, the average was 800 grammes for the 
vomited matter and 100 grammes (= 1543*23 grains) for the urine 
(Plate VII). 

During this new phase, in which the disease ofî'ered itself for in- 
vestigation, we were not under so favorable conditions as on the 
previous occasion. The patientas right arm had become nearly 
quite free. Hence it was urgent that we should protect ourselves 
again st every possible cause of error. 

In addition to the customary surveillance, which was not relaxed 
for a moment, we had recourse to the following précautions :— the 
patient's bed was carefully examined from time to time, and neither 
vessels nor cathéters were allowed to reraain at lier disposai. Finally, 
I succeeded in persuading her that it might, perhaps, be bénéficiai 
on account of the contracture that still persisted in the left arm to 
make use of a strait jacket. To this she consented. The applica- 
tion of the strait jacket was not, however, absolutely continuons ; it 



CHEMICAL ANALYSES. 239 

was removed at meal-times, when the patient was watched by the 
person who fed her. 

At différent periods, during the month, M. Gréhant analysed the 
urine and the vomited matter rendered in twelve days. During this 
lapse of time, the daily average of the urine was 206 grammes, 
containing 5*09 grammes of urea. The daily average of vomited 
matter, amountingto ofii grammes, yielded 3"i38 grammes of urea. 
Adding together the two totals of urea rendered, we obtained the 
low figure of 5*233 grammes. I can show you a spécimen of the 
oxalate of urea which M. Gréhant extracted from the matter vomited 
during the four and twenty hours. We shall make use of this 
resuit in a moment. 

We did not discover, any more than on the previous occasion, the 
existence of a supplemental élimination by the skin or intestines. 
The patient is habitually constipated, and we did not observe, at 
either time, any peculiarity in relation to the external tégument. 
Her gênerai health has not undergone any noteworthy altération, 
and the température never was above 37° C. ( = 98*6° T.) and some 
tenths.^ 

Thus, gentlemen, this new investigation confirms the accuracy of 
the first, and both concur to establish the existence of Jiysterical 
ischuria, with erratic jjamria as aproven pathological phenomenon, 
utterlybeyondthe possibility of simulation. If this conclusion belegiti- 
mate, it is obvious that some value must be attached to the records of 
former cases. It is only requisite to separate the truth from what is 
fictitious, to eliminate, for instance, certain extraordinary phenomena 
such as the flow of urine from the nose, eyes, &c., and the vomiting 
of fsecal matter. Some of thèse accounts, indeed, exhibit, in ail their 
détails, the characteristics of a truthful statement. We would place 

1 Etch — lias presented, during the présent year (1875), ^ ^^^ period of 
liysterical ischuria. On examining the table (PL X), which represeuts the 
quautity of urine rendered each day, and the results of 112 chemical analyses 
made by M. P. Regnard, we notice that, during three moiiths, the patient ren- 
dered from fifteen to twenty grammes of urine daily, containing from three to 
four decigrammes of urea. Some days, however, in the midst of painful fits, the 
patient in a few hours emitted up to four litres of urine, containing 27 
grammes of urea. During this period, Etch — had no vomiting, by which urea 
might hâve been evacuated, as happened on the occasions specified in the 
lecture. (See in référence to this communication which we made in con- 
junction with M. P. Regnard to the ' Société de Biologie,' 3 Juilliet, 1875). 
We shall hâve occasion, further on, to mention under what circumstances this 
ischuria suddenly ceased. (See Lecture XII.) 



■240 GEAYITY OF ORDINAEY ANUEIA. 

in this categorj the case reported by Dr. Girdlestoiie (of Yarmouth), 
and some others besides. 

VI. 

I désire now, gentlemen^ to investigate with you, whether the 
contradiction we noticed between ord'mary anuria observed in man, 
or exi^erlmental anuna produced in animais, on the one hand, and 
hystencal ischuria, on the other, be quite as absolute as it seemed at 
iirst sight. 

In the first group of cases, death is nearly certain to happen within 
a brief space; in the second, the gênerai health is kept up in a 
tolerably perfect state for an indefiuite period. The opposition is 
therefore extremely marked. Is it not, however, possible, by a 
careful scrutiny of ail the circumstances, to arrive at the reason of 
this discordance ? I am far from being in a position to solve the 
problem in a decided manner. Hence, I must content myself with 
stating an hypothesis which, perhaps, may seem plausible to you, 
but which I request you, in any case, to take only for what it is 
worth. 

That animais should always succumb after nephrotomy, or per- 
manent ligature of the ureters, is very natural. But we hâve 
a right to ask what would happen if an experiment could be 
made in which, for instance, the obstruction of the ureters, instead 
of being permanent, was intermittent ? Would existence be pro- 
longed if, in- such conditions, a regular alternation were estab- 
lished between the rénal and the supplemental élimination? In 
spite of the interest which would attach to the solution of this 
problem, I put it aside in order to corne to the question of human 
pathology. 

Let us then résume the considération of calculons obstruction 
of the ureters, to which we referred above. 

The first remark which suggests itself to the mind is the follow- 
ing : In our patient, complète anuresis never lasted longer than a 
period of ten days. Now, according to what we hâve mentioned, 
that is not the extrême limit at which, in obstruction of the ureters, 
the symptoms of miemic poisoning necessarily appear, since, in 
Paget's case, the i)atient preserved his gênerai health and functional 
integrity till the fourteenth day. No doubt the quantity of urine 
secreted by Etch — on alternate days was very minute, but small as 
itwas, it is of real importance; for every author, since Halford, has 



COMPARATIVE BENIGNITT OF HYSTERICAL ISCHURIA. 241 

Tecognised the great relief and improvement whicli ensues in the 
ureter-iscliuria of calculons patients, on tlie émission of the smallest 
quantity of urine. 

Again, we liave anotlier peculiarity :— calculous patients are 
suddenly sei/ed, surprised as it were in the very midst of good 
health, whilst, to judge from my own observations, hysterical ischuria 
only arrives gradually at its apogée. Perhaps, there is a question 
of Itah'it hère, of whicli it is well to take heed. Far be it from 
me, hovvever, to suppose that hysterical patients enjoy a peculiar 
immuuity, a kind of Mithridatism, with respect to urœmic in- 
toxication. The résistance they présent, in the conditions we are 
considering, is most probably due to another cause — the question 
hère is rather oue of doses. Let me explain. 

The insignificant quantity of urea eliminated by our patient, both 
in the urine and the vomited matter, must hâve caught your attention. 
During a period of twelve days, we hâve said, she only got rid of 
five grammes of urea daily. This amount is, you are aware^ far 
below what Schérer found in the case of an insane man, who had 
been fasting for three weeks — from nine to ten grammes of urea were 
the quantity found in that instance.^ We hâve also seeu that there 
was no reason for believing that, in our patient, there jv^as any 
élimination of urea by the perspiration^ or the stools. IN^ow, in 
every case of poisoniug, and urœmia is probably no exception to 
the rule, we must take the dose as an élément to be considered. 

Is it not, then, most likely that this very diminution of the amount 
of urea — which doubtless corresponded to a corrélative diminution 
of extractivematters — should account, in our patient, for the absence 
of every symptom of urœmic intoxication ? We are thus indaced to 
admit that in this case of Etch — there was, so long as the ischuria 

' It is proper to meutioii that tlie différence of sex aud couditiou may liave 
contributed somewhat to this disparity of resulls. With respect to sex, Eeigel 
taking an average of 58 analyses, found that 35*6 grammes of urea were 
yielded by a m aie in the twenty-four hours, whilst a female yielded only 27.6, 
in the same time. It must also be remembered that Etch — was in euforced 
inaction, duriug the investigation ; and that she seems to hâve been unable to 
receive nuich nutritions food. Lehmann, who found 53"i9 grammes of urea in 
the urine rendered on the eighth day of a strictly nitrogenous diet, was able 
to reduce the amount to i5"4i grammes, by living for eight days on uon- 
azotized food. Thèse facts go to support Professor Charcot's views. (S.) 

- According to the researches of M. Favre there are in the normal state 
only o'43 gr. of urea in 10,000 "grammes of perspiration. (S.) 

16 



242 MEGHAKISM OF HYSTîlElCAL ISCHUEIA. 

lastecl, a decrease of activity in the phenomena of disassimilation, 
manifesting itself by an absolute diminution of excrementitious 
matter. 

This condition, besides, is probably common to a group of hys- 
terical cases. In fact, it lias been long remarked that some of tliese 
patients when subject to uncontroUable vomiting, bear up wonder- 
fully against the influence of a restricted and insufficient alimenta- 
tion, without losing tlieir plumpness or suffering any disturbance 
in tlieir health worth noticing.i It would certainly be of interest, 
under such circumstances, to make comparative analyses day by day, 
of tlie blood and urine, in order to ascertain tlie amounts of urea 
and extractive matters présent. We might, possibly, by this means 
obtain the solution of the problem which I can only indicate hère. 

VII. 

Wliat is the mechanism on which hysterical ischuria dépends ? 
Wliat is the seat of the obstacle which hinders the sécrétion of urine 
from being effected ? The urethra and the bladder are evidently 
not incriminated. Is the obstacle in the ureter, or in the kidney 
itself ? No reason exists for suspecting the existence of phlegmasia 
of the rénal glands or the ureters; the composition of the urine, and 
the other symptoras, likewise, are opposed to such an hypothesis. It is 
more allowable to consider that we hâve hère to deal with some action 
of the nervous system. The influence of the nervous System on the 
sécrétion of urine is not a doubtful matter. It may sufhce to remind 
you, by way of illustration, that temporary suppression of urine may 
be produced in dogs by the mère fact of laying open the abdomen, 
as» Isl. Claude Bernard has observed ; and that, in the opération for 

^ A singular case of this kind is mentioned by Sirï. Watson ('Lectures on 
tbe Principles and Practice of Pliysic,' t. i, art. i, p. 704, London, 1857. 
''A romantic girl," he says, " was for some months under my care iu tlie hos- 
pital witli that complaint (liysterical hœmatemesis). She vomited such 
«juautities of davk blood (which did not coagulate, however), as I woukl not hâve 
believed if I had not seenthem. Day aficr day there were potfuls of this stufi', 
yefe she did not losc flesh, and she menstruatcd regularly ; and what was very 
curious, tho vomiting was always suspended during the monstrual pcriod and 
recuvred again so soon as the natural discliargeccased. . . . At last I senthcr 
away just as bad as wlicn slïcentered tlic hospitah" She rccovercd aftcrwards 
oagetting married. Tlio alternai ion hcrc may bc comparcd wifh that poiuted 
out by M. Gharcot. (S.) 



MECHANISM OF HYSTEETCAL ISOHUETA. 243 

vesico-vaginal listula, it also occasionally happens (as Jobert de 
Lamballe remarked) tliat tlie urine may be suppressed for a certain: 
period. 

May it not be tbat, in the case of our patient^ there existed a 
spasmodic oblitération of the ureters ? That thèse conduits possess 
very markcd contractile properties is an admitted fact: thus, Mulder 
observed them contracting energetically in a patient suffering from 
ecstrophy of the bladder, and Valentin reports having notieed a 
very decided contraction supervening under the influence of irritation 
of the nervous centres.^ This supposition appears to be supported 
by analogical reasouing, for in hysterical patients we frequentlj 
find long-continued contraction of the tongue, the œsophagus, &c. 
Hysterical ischuria should, consequently, be paralleled with calculous 
oblitération of the ureters. Unfortunately, there are objections of 
some weight to be alleged against this view. 

The expérimental researches of Herr Max Hermann demonstrate, 
you are aware, that the proportion of urea to the quantity of urine 
voided^ diminishes when there is counter-pressure of the ureter. If 
the pressure reach 0"o6o millimètres of mercury no more urea is found.. 

Mr. lloberts (of Manchester)^ confirmed the accuracy of this state- 

^ Donders' ' Physiologie.' 

- " Tiie Pathology of Suppression of Urine," Lu 'The Lancet,' iS68, Maj 
23 and 30, — 1870, JuneiS; 'Mouvement Médicale/ 1871, pp. 22,32,128» 

Sinee this Lecture was delivered by M. Charcot, M. Ch. Feruet has com- 
nninicatcd to the Société Médicale des Hôpitaux a note entitled " De l'oligurie 
et de i'auurie hystériques et des vomissements qui les accompagnent " (' Unioa 
Médicale,' 17 Avril, 1873, p. 566). A f ter having stated M. Charcot's opinions, M. 
Ch. Feruet reports an interesting case, of whichthe following is a summary: — 

Marie L — , aged ipyears, cliloro-anaîmic, menstruatedat sixteen years. Her 
menstruation has always been very irregular. A sister of the patient is subject 
to fréquent liysterical seizures. In Jauuary, 1871, Marie L — got a friglit, 
which threw her into an hysterical fît. In May, extrême debility. uneasiriess, 
pains in tlie limbs (strengthening regimen, bark, iron, sea-bathing.) At the 
end of the month of August, after a sea-bath, Marie L — ■ was takeu for the 
first tinic witli vomiting. " She began by throwing up the solid food, then, 
after a few days, she vomited ail she took . . . Thèse repeated vomitings eoii- 
tiuued, witliout iutermissiou, till the month of October, then subsided for a fort- 
night, wlien thcy recommeuced with their original inteusity and persisted 
without respite. ... In March, 1873, she was admitted to the Hôtel-Dieui 
(under M. Moissenet's charge). 

Treatm^nt. — Cold lotions, ice and Champagne, blister with morphis, 
to the epigastrium. The vomitings gradually diminisbed, and ouly appeared 
again at iutervals ; the patient left the hospital ou the fifteenth of April, the 



244 MECHANISM OF HYSTERICAL ISCHUEIA. 

inentinits relation to inan. In a case of calculons obstrnction of the 
ureter, tliere escaped a small quantity of clear urine, containing only 
50 centigrammes of urea per looo grammes. Now, in tlie case 
of our patient, tlie urine contained 15 grammes of urea per 1000 
grammes, — an amount approximating to the normal standard. 

Judging from this, gentlemen, the obstacle in hysterical ischuria 
would not lie in the ureters. Where then does it réside ? Should 
we invoke an influence of the nervous System analogous to that 
which Ludwig discovered in the case of the salivary gland ? In the 
absence of ail information on this point, we are compelled to leave 
the question in suspense. 

vomitings having ceased. During the mouths of May aud Juue, rare vomitings. 
They returncd iu July, after some vexations, and again stopped, owiug probably 
to the influence of bromideof potassium. At the end of July, another emotional 
disturbance set them again in action with their former frequeucy and persistence. 

Marie L — was admitted a second time to the Hotel-Dieu, on the i8th 
of August, 1872. She then came under M. Ch. Fernet's observation, when she 
presented the following symptoms : excessive debility ; anœmia very niarked, 
characterised especially by discoloration of the skin and mucous membranes ; 
intercostal neuralgia; ovarian sensibility developed ou the left side, paiuful on 
pressure ; auœsthesia existing on différent points of the skin; complète plantar 
ansesthesia ; profound analgesia of the superior extremities ; achromatopsia of 
the left eye, which cannot distinguish yellow tints ; vomitings. The paiient 
allèges that, since their appearance, she only voided a very minute quantity of 
urine, that she often remains for scveral days without voiding eveu a drop. 

SeptemLer 4. — Milk-diet, exclus ively. Prom the 4th to the pth September, 
there was but one émission of urine (about 150 grammes). From this epoch, 
M. Ch. Eeruet caused to be exactly weighed, 1° the quantity of food taken, 
and 2° the amount of urine voided aud of matters vomited, aud, after record- 
ing thèse quantities day by day, he says: "The examination of this table 
allows us to establish a close connection between the state of the urinary 
function and the vomitings. In a first period, comprised between the uintli 
and sixteenth September, that is to say, eight entire days, the urine was 
completely suppressed during the first six days, and its quantity was very 
scanty during tlie last two ; now, iu this period, the patient beiug on a niilk 
diet, vomited a quantity of liquid matter, at first équivalent to one-half or 
three-fourths of the fluids swallowed during the iîrst four days, then a quantity 
perceptibly equal to the quantity of milk taken during the last four days. 

"In a second period, comprising nine days (from the i8th to the 26th Sept.), 
'the quantity of vomited matters secms to hâve diminishcd ; but this is not exactly 
the case, as we see on comparing it with the quantity of food taken. The diet 
having been changed, and beiug now composcd of cold soup {bouillon), of raw 
becf, aud of lemonade, the vomited matter still represents almost the whole of 
liic ingesta. Now, during this time, there was a little urine the first two days 



ANOTHER CASE OF HYSTEEIOAL ISCHURIA. 245 

(15 grammes and 250 gr.), but its émission was suspended during the seven 
days following. 

"Fiualiy, iu a tliird period, lastiug four days, (frora the 27tli to 3oth Sept.), 
we see the urinary functioii re-established, and the amount of urine reaching 
the normal standard (1000 grammes, 500 gr., iioo gr. the last two days) ; at 
the same time, the vomitings diminished on the second day and subsided on the 
third and fourth." 

Desirous of ascertaining whether, as indicated by M. Charcot, the vomiting 
might not be attributable to the supplemental élimination of urea by the stomach, 
M. Ch. Feruet requested M. E. Hardy to analyse the urine and the vomited 
matter. From a summarised table of thèse analyses, it appears that " the urea was 
alway s présent to auoteworthy amount (from o','^5 gr., to l'S) grammes) in the 
vomited matter ; also, when the sécrétion of urine was suppressed, the quantity 
of urea contained in the vomited matter was gradually increased during that 
space of time. From the I7th to the 27th Sept., the quantity rose from 0.62 
to 1.08 grammes. Finally, from the day when the urine issuing from the 
bladder reached what might be considered a normal amount, the urea 
diminished in the gastric sécrétion, disappearing doubtless at the same time 
as the vomiting." 

A moral iuiluence — the administration of the pills termed "fulminantes" 
{mica panis) — caused a sudden change in the condition of Marie L — , dating 
from the 27th September. The vomiting ceased, the sécrétion of urine resumed 
its course. Finally, the patient left the hospital, in very fair health, in the 
course of November. M. Ch. Fernet, ia concluding his note, points out the 
iiumerous analogies between this case and that pf M. Charcot's patient. 

We may mention also a tbesis of M. Secouet, ' Des vomissements urémiques 
chez les femmes hystériques,' (Paris, avril, 1873), which contains the report of a 
case that, though imperfect iu some respects, should apparently be classed in 
the category of hysterical ischuria. (B.) 



LECTURE X. 

HYSTERICAL HEMIANiSSTHESIA. 

tSuMMARY. — Ilemimmsthesia and ovarian hyper œstliesia in, hysteria. 
Fréquent association qf thèse two symjptoms. Frequency of 
hemianasthcsia in hysterïcal 2^at'ients ; iisvarieties, complète or 
incomplète. Char acier s of hysterical hemianœsthesia. Ischœmia 
and the " Convulsïonnaires" Lésions of spécial sensés. Achro- 
matopsia. Relations hetween hemianœsthesia, ovarian hyper- 
iBsthesia, paresis and contracture. Variation of sympio?ns in 
hysteria. Diagnostic value of hysterical hemian(esthesia ; 
necessary restrictions. 

Hemianœsthesia depending on certain encephalic lésions. 
Its analogies vnth hysterical hemianœsthesia. Cases in tohick 
encephalic hemianœsthesia resembles hysterical hemianœsthesia. 
Seat of the encephalic lésions capable of prodncing hemian- 
œsthesia. Fiinctions of the optic thalaraus; British theory ; 
French theory. Criticism. Germon nomenclature qf différent 
parts of the encephalon. Its advantages as regards the circum- 
scription of lésions. Cases of hemianœsthesia recorded hy Tiirck; 
spécial seat of the encephalic lésions in thèse cases. Observa- 
tion of M. Magnan. Altération of spécial sensés. 

Gentlemen, — There are two points in the history of liysteria, 
ïipoîi which I wish to lay particular empliasis, in this and tlie fol- 
îowiiig lectures. Thèse are, on the one hand, hysterical hemianœs- 
thesia, and on the other, ovarian hyper œsthesia. If I set tlicse two 
phenomena side by side, it is because they are generally found as- 
sociated together in the same patients. With référence to ovarian 
hyperœsthesia, I hope to render évident to you the infhionce of 
preiênre on the ovarian région — an influence formerly acknowlcdged, 
but afterwards denicd — ovcr the production of tlic phenomena 



OVAlilAN HYSTEltlA. 247 

of the hysterical seizure. I shali sliow you that this opération 
détermines, eitlier the premouitory symptoms merely of the hys- 
terical fit, or, in a certain number of cases, the complète seizure. 
You will thus be enabled to verify the accuracy of the assertion 
formerly made by Professor Scliutzenberger, witli respect to this phe- 
nomenon, in spite of the contradictions offered by certain observers. 
I shall likewise show you a method which I hâve discovered, or 
rather re-discovered, whicli, in the case of some patients, enables us 
to arrest the course of even the most intense hysterical fit, — I refer 
to the syste malle compression of the ovarian région. M. Briquet 
dénies that this compression bas any real effect. That is an opinion 
which I cannot share, and this leads me to make a gênerai remark in 
référence to M. Briquet's book.i The work is an excellent one, the 
resuit of minute observation and patient industry, but it has perhaps 
one weak side ; ail that relates to the ovary and the utérus is treated 
in a spirit which seeuis very singular in a physician. It exhibits a 
kind of prudery, an unaccountable sentimentality. It appears as 
though, in référence to thèse questions, the author's mind were 
always preoccupied by one dominant idea : " In attempting to at- 
tribute everything to the ovary and utérus," he says for instance, 
somewhere, '' hysteria is made a disorder of lubricity, a shameful 
afî'ection, which is calculated to render hysterical patients objects of 
loathing and pity/^ 

Eeally, gentlemen, that is not the question. Por my own part, I 
am far from believing that lubricity is always at work in hysteria ; 
I am even convinced of the contrary. Nor am I eitlier a strict 
partisan of the old doctrine which taught that the source of ail 
hysteria résides in the génital organs ; but, with Schutzenberger, I 
believe it to be absolutely demonstrated that, in a spécial form of 
hysteria, — which I shall term, if you please, the ovarian form, — 
the ovary does play an important part." Pive patients whom I 
shall présent to you in succession are, if I mistake not, manifest 
examples of this form of hysteria ; you can verify the accuracy of 
the description I am about to give, by personal examination. 

' Briquet, ' Traité clinique et thérapeutique de l'hystérie/ Paris, 1859. 

" Grisolle ('Traité de Pathologie luterue,' 9e édit., t. ii, p. 844) mentions 
the case of a girl, aged 22, who had neither vagiua nor utérus, aud yet was 
subject to iiiost violent fits of hysteria. Ou autopsy, MM. Chassaignac and 
Prévost could discover no trace of a utérus, but found, in the ovariau régions, 
two bodies which were apparently the ovaries. The patient had, every month, 
exhibited ail tlie symptoms of pre-catamenial congestion. (S.) 



248 HYSTERICAL HEMIAN^STHESIA. 

I. 

You are ail acquainted witli the Jiemiantestkesla qf hi/sterical 
patients. There woulcl be some ingratitude in not knowiug the 
nature of this symptom, for it lias been discovered by purely Ereuch 
investigations. Piorry, Macario, and Gendrin^ hâve each of them,. 
in his turn, described it and dwelt upon its characteristics. Not long 
after them, Szokalsky made it known in Germany ; but nothing 
remained for him to do save to confirm by observations^ which are,, 
bowever, very meritorious^ the facts that had been already declared 
by our countrymen. 

In order to keep witliin bounds, I shall enter upon a discussion 
of complète Jieinianccstliesia only, sucli as we find in intense cases. 
This will be suiïicient for my présent purpose. Even in the degree 
mentioned, it is a fréquent syinptom, since according to M. Briquet, it 
obtains in 93 cases out of 400. Considered with respect to position, 
we find, according to the same author, that in 70 cases the left 
side is affected; and in 20, the right. 

You know what happens uuder such circumstances. Sapposing 
that the two halves of the body are vertically divided by an antero- 
posterior plane, one entire side — face, neck, body, &c. — will hâve 
lost the sensé of feeling ; and though this loss of sensibility very 
often affects the superficial parts merely, — the external tégument, — yet 
it sometimes also invades the deeper régions, affecting the muscles, 
bones, and articulations. 

Hijstencal hemianasthesia shows itself, as you are aware, under 
two principal aspects; it is complète or incomplète. Ânalgesia, 
with or without insensibility to beat or cold, or thermo-anœsthesia is 
one of the commonest varieties of this species. The distinct manner 
in which the ansesthetic parts are separated from the healthy parts 
is also an important characteristic of hysterical hemianœsthesia. On 
the head, face, neck and body the démarcation is often perfect and 
very closely corresponds with the médian line. Another symptom, 
well deserving of mention, is coustituted by the comparative pallor 
and coldness of the auœsthctic side. Thèse phenomeua, conjoined 
with a more or less permanent ischéemia, hâve been many times 
observcd. l'^xamples of them hâve been givcn by Brown-Srquard 
and Liégeois.i j^ difliculty in inducing bleeding by pricking the 
anœsthetic parts with a pin may, in intense cases, be a characteristic 
of the ischîL'mia in question. 

' Liégeois, 'Mémoires de lu Sociétc de Biologie,' 3e série, l, i, p. 274. 



HYSTERICAL HEMIAN^STHESIA : ISCHURI;\. 249^ 

I noticed tliis peculiarity on a former occasion. The matter came 
under my observation in this way : on leeches being applied to a 
patient affected by hysterical hemianfesthesia^ I saw that their bites 
yielded very little blood on the auœsthetic side^ whilst on the healthy 
side it flowed as usual. Grisolle, wlio, as you are aware, was a very 
wise and exact observer, liad noted the same phenomenon. 

This ischfcmia which, indeed, is rather rare when so intense, may 
furnish an explanation of certain reputedly miraculous occurrences. 
Thus, it is stated, that, in the épidémie of Saint Medard, the sword- 
blows given to the " Convulsionnaires" did not cause bleeding. The 
reality of the occurrence cannot be rejected without examination. 
If it be true that many of thèse " Convulsionnaires " were guilty of 
trickery, we are nevertheless compelled to acknowledge, after an 
attentive study of the question, that most of the phenomeua which 
they presented, and of which history has given us a naive descrip- 
tioni were not entirely simulated, but merely amplified and exag- 
gerated. It has been critically demonstrated that hysteria carried 
to an extrême, was almost alvvays the active agent in thèse cases ; 
and in order that a wound, such as that made by a sword, should 
not, when inflicted on thèse anœsthetic women, hâve caused bleed- 
ing, it was only necessary, as you may infer from what précèdes, 
that the instrument should not hâve entered too deeply. 

There are other characters also of hysterical hemiausesthesia which 
are deserving of ail our attention, from a clinicai as well as from a 
theoretical point of view. The mucous ■membranes are affected, on 
one side of the body, in the same manner as the external tégument. 
The organs of the sensés themselves are affected to some extent in 
the anœsthetic side. Tade may hâve vanished in the correspond- 
ing half of the tongue^ from tip to base. The sensé of smell is 
less acute. Vision is weakened in a very remarkable manner, and 
if amblyopia occupy the left side, we may meet with a most note- 
worthy phenomenon, to which M. Galezowski has called attention, 
and which he désignâtes by the name of acliromatopsia. However, 
we shall return to this topic. 

Hysterical hemianœstJiesia does not seem to affect the viscera. 
Thus, to mention the ovary merely, we find hyperaîsthesia and not 
ansesthesia présent. That organ may be very painful on pressure, when 

' Carré de Moutgerori, ' La Vérité des Miracles opérés à l'intercession d& 
M. de Paris et autres Appelants,' &c., 1737. 



250 HEMIAN.ESTHESIA AND OVAKIAN HYPEE.ESTHESIA. 

tlie abdominal wall is perfectly insensible. TsTow, gentlemen, there 
exists a most remarkable relation between tlie position of tlie hemian- 
sesthesia and tliat et" the ovarian liypersesthesia. If tlie former occupy 
theleft side, the hemiauœsthesia occupies the left side, and vice verset. 
When ovarian hypera^sthesia is double, it is the rulethat the anfusthesia 
shall présent itself in a generahzed form, and it consequently occupies 
nearly the whole, or quite the whole of the body. 

Not only does such a relationship exist between the seat of the 
liemianaîsthesia and that of the ovarian hypersesthesia, but a similar re- 
lationship exists with regard to the paresis, or to the contracture of 
the limbs. Thus, when the paresis or the contracture supervenes^ it 
always shows itself on the same side with the hemianœsthesia. 

The hemianaîsthesia, as described, is, in the clinical history of 
hysteria, a syniptom of the greater importance, inasmuch as it is 
well-nigh permanent. The only variations which it exhibits, are dépen- 
dent upon degree, on the intensity of the phenomena which consti- 
tute it, and occasionally, w^e should also mention, on the fluctuation 
of some of thèse phenomena. 

Achromatopsia belongs to the number : it was distinctly and re- 
peatedly observed in oue of our patients, a few weeks ago, from 
whom it bas now completely disappeared. 

It is uecessary to bear in miud that hemiansesthesia is a sympton 
which requires to be sought for, as M. Lasègue very judiciously re- 
marks.i There are, in fact, many patients who are quite surprised 
■when its existence is revealed to them. 

II. 

I propose now to investigate to what extent hemianœsthesia, such 
as we hâve described it, is a symptom proper to hysteria. In rcality, 
it is very rare for it to be reproduced, with the gênerai grouping of 
ail its characteristics, by any other disease. Its well-established ex- 
istence is, therefore, a valuable indication, one which will often reveal 
the real nature of many symptoms, which would otherwise remain 
doubtful. That is a point on which M. Briquet was right to lay 
great stress. In order to illustratc the importance of this fact, lie 
relates the case of a woman who, after a violent émotion, fell rapidly 
into a more or less profound coma, witli or without prcmonitory 
convulsions {i.e. the comatosc form of hysteria), and who was seen, 
on recovering her sensés, to be stricken with more or less com])lete 
' ' Archives Générales de Médecine,' 1864, t. i, p. 385. 



HEMIANyESTHESIA of encephalio origin. 251 

liemiplegia. Hère we hâve a group of symptoms which it is not 
very rare to meet with in practice, and, on such an occurrence, it niay 
happen tliat the physician will feel himself placed in a very em- 
barrassing position. Now, the présence of hemiauœsthesia, arrayed 
in ail its characteristics which would most probably be found on 
such occasion, might then, according to M. Briquet, indicate the 
true patli to the observer. This assertion is perfectly accurate ; I 
hâve no fault to fiud with it, except as regards one point. 

If it be true that hemiansesthesia is an almost spécifie symptom, 
inasmuch as it is not found with the same characteristics in the 
immense majority of cases of material lésions of the encephalon 
(hœmorrhage, softening, tumours), we cannot admit this to be an 
absolute characteristic. It is, above ail, inaccurate to say that t/ie 
liemianœsthesia, developed tmder the influence of enccplialïc lésions, 
always differsfrom hysterical hemianœsthesia, hy tliefact that^ in the 
former case, the s¥in of the face does not participate in the insensi- 
bility, or that, when it exists, it never occiqnes the savie side as the 
insenslbility of the mémhers. This is an inaccuracy which lias been 
reproduced, almost in the same terms, in the otherwise very interest- 
ing thesis of M. Lébreton.^ 

I feel some répugnance in again attacking the remarkable work 
of M. Briquet, but the more estimable the work — and it is justly 
esteemed, — the more serions become any inaccuracies which may 
hâve slipped into it. This relîection will, I hope, justify me in 
criticising it. 

Gentlemen, there are cases, which, though indeed exceptional, are 

thoroughly authentic, where certain circumscribed cérébral lésions (en 

foyer), may cause the production of hemianjesthesia with ail the signs 

that characterise it in hysteria — or very nearly ail. Allow me to 

discuss this subject, in some détail. 

The classic doctrine, at least amongst us, — a doctrine which, 
besides, appeals to the data of clinical observation, and to those fur- 
nished by experiments on animais, — teaches that circumscribed céré- 
bral lésions {en foyer), which so profoundly aflect the power of motion, 
especially when they occupy the région of the optic thalamus and 
corpus striaium, produce but little efFect as regards sensibility. 
Erom this point of view, gentlemen, the resuit is said to be always 

1 Lebreton, 'Des differeutes variétés de la paraljsie hystérique,' TLcse de 
Paris, 1868. 



252 ENCEPHALIO LESIONS. 

the same, whether tlie lésions occupy specially the corpus striatum, 
tlie optic thalamus, or the rampart of the amygdalœ (claustrum). 

At first glance, when in présence of the sudden developed lésions 
which détermine an apoplectic fit, and which afFect any one of the 
points just enumerated, the symptom which strikes the observer is 
a hemiplegia, more marked in the upper than in the lower ex- 
tremity, and accompanied by flaccidity. 

In the face, the paralysis usually affects the buccinator and the 
orbicularis oris ; the tongue also is mostly protuded to the para- 
lysed side. In addition to motor-paralysis cornes paralysis of the 
vaso-motor nerves, manifested by an élévation of température in the 
paralysed limb. Occasionally, this vaso-motor paralysis makes i^s 
appearance from the outset. 

As to sensibility, it is not modified in a perceptible manner, or 
least not in a durahle manner. The spécial sensés présent no serions 
altérations, exceptsome complication supervenes, as where embolism of 
tlie arierïa centralis retinœ occurs (in cases of brain-softening consé- 
cutive on the migration of a valvular végétation), or where compres- 
sion, by contiguity, of the tractus opticus happens (on occurrence of a 
somewhat voluminous hœmorrhagic lésion) . Such is a summary of the 
symptoms whicli are met with in the immense majority of cases of 
haemorrhage and softening affecting the points of the encephalon we 
hâve meutioned. 

Undoubtedly, gentlemen, that is what takes place, in the great 
majority of cases. But, the chapter of exceptions accompanies the 
rule. There are cases, and I hâve myself observed several of this 
kind, in which sensibility is affected in a prédominant manner, and 
in which ansesthesia persists, even after the recovery of motion. 

Such altérations of sensibility may présent themselves with the 
foUowing characters. The ansesthesia alïects one entire half of the 
body and stops just at the médian line. Tlie correspouding half 
of the face, both as regards the skin and the mucous mem- 
branes, shows insensibility, exactly as in hysterical hemiansesthesia. 
Tlien also analgesia and thermo-aïuesthesia may be observed, 
with conservation of tactual sensibihty, as MM. Landois and 
Mosler- hâve ascertained. Einally, there are also cases, though of 
more rare occurrence and as y et imperfectly described, but haviug 
still their own importance, which render it probable that, under 

^ Hirscb, ' Klinisclie fragments,' I. Abth., p. 207, Kœuigsberg, 1857. 
- Landois et Moslcr, ' Berliiier Klin. Wochcns./ 1868, p. 401. 



BEITISH THEOEY. 253 

sucli circumstances, altérations of the spécial sensés may exist 
on the side opposite to the encephalic lésion, or, in other words, on 
the same side with the hemiansesthesia. 

The physiciaus of the last century hâve already remarked thèse 
exceptional phenomena. Borsieri, among others, relates the history 
of a patient who, three months before, had been stricken with 
apoplexy, and in whom aneesthesia still persisted^ although the 
power of movement had returned. He quotes some other cases of 
the same kind from différent authors.^ 

Analogous cases bave been mentioned by Abercrombie^ Andral, 
and, in later days, by Hirsch, Leubuscher, Broadbent, Hughlings- 
Jackson/ and especially by Tiirck. The latter alone lias been able 
to furnish décisive data in référence to the position occupied by 
the encephalic lésions in snch cases. 

When the hemianœsthesia présents itself with thèse characters, the 
optic thalamus is almost always affected in a prédominant, if not 
in an exclusive manner. For my own part, I hâve seen hemianses- 
thesia superadded to hemiplegia, in many patients affected with 
cérébral hsemorrhage, and, in such cases, on post-mortem examina- 
tion I always found the lésion of the optic thalamus, the existence 
of which during life I had ventured to announce. 

From what précèdes, gentlemen, should we conclude that tlie 
lésion of the optic thalamus is the real organic cause of the hemian - 
festhesia observed in ail thèse cases ? That is a question deserving of 
discussion. I am thus led to speak of the physiological theory, 
wbicli may be called the British theory, because it was, I believe, 
first published and maintained by Messrs. Todd and Carpenter, two 
British authors. According to this theory, the ojii'ic tJialamus is the 
centre of perception of tactual impressions ; it would, in some degree, 
correspond to the posterior cornua of the grey substance of the spinal 
cord. The corpus striatnm would be the terminal of the viotor 
tractus and connected with the exécution of voluntary movements ; 
it would be analogue of the anterior cornua of the cord. 

This theory, of which Schrœder van der Kolk"' has shown himself the 
avowed partisan, is, if we might use the word, the antipodes of the 

^ Borsieri, ' Inst. pract./ vol. iii, p. 76. 

" H. Jackson, ' Note on the Eunctions of the Optic Thalamus.' lu ' Lon- 
(lon Hospital Reports,' 1866, t. iii, p. 373. 

2 Schrœder van der Kolk, ' Pathol. und Thérapie der Geistenkrankheiten.' 
Brauuschweig, 1863, p. 20, 



254 FEENCH THEOEY. 

Prencli theory, which you will find set fortli in a very complète 
manner in M. Vulpian's Lectures. According to the latter view, tlie 
centre on which sensitive impressions are transformed into sensations 
would not be in the brain proper, because an animal, from which the 
brain, including the optic thalamus and the corpus striatum, has 
been removed, continues to see, to hear, and to feel pain, &c. The 
centre of sensitive impressions would therefore réside lower down, in 
the 2)rotuberantia and ]ierhaps also in the crura cerebri. 

Under this hypothesis, the foUowing is the manner in which its 
advocates regard, in the pathological domain, tliose authentic facts 
which show a lésion of the optic thalamus coinciding with the 
decrease or abolition of sensibility on the side of the body stricken 
with hemiplegia. They say, and their allégation is perfectly correct, 
that, in such cases, we hâve frequently to do with récent lésions, sucli 
as mtra-encephalic hœmorrhage, or ramollissement, or tumours — 
lésions by which the optic thalamus is extremely distended, and 
which consequently, may hâve the effect of determining the com- 
pression of the adjacent parts, — of the crura cerebri for instance. It 
is, on the other hand, well established that, in a number of cases, 
the optic thalamus may be injured, even gravely and throughout 
a large portion of its extent, without being followed by any spécial 
disorder in the transmission of sensitive impressions. 

To the last argument, the Britisli authors, M. Broadbent ^ among 
othors, oppose the plea that the optic thalamus, the presumed centre 
of sensitive impressions, should doubtless be assimilated to the grey 
axis of the spinal cord — the latter, it is known, continues to trans- 
mit thèse impressions even when it has suffered the most serions 
dérangement, if only a small remuant of grey matter persist, capable 
of Connecting its lower with its upper extremities. I oonfess that 
the comparison seems to me far-fctched, especially from the mo- 
ment it is laid down as a principle that the optic thalamus should 
be considered a centre; for, so far as regards the transmission of 
sfiflsitive impressions, the grey axis of the cord is manifestly merely 
a oonductor. 

However this may be, gentlemen, such is the statc of the ques- 
tion. In my opinion, the disi)uted points cannot be definitely 
solved, exccpt by means of careful clinical observation, verified by 
stodious anatomical investigations, the chicf aiin of which should be 
to establish, with great précision, the seat of the enccphalic lésions, 
' Broatlbcnt, ' Médical Society,' Loudon, 1865, and ' Mcd.-Cliir. Kevicw.' 



EEQUISITE CONDITIONS. 255 

to wliicli the symptoms recorded during life miglit be correlated. 
And the circumstances of the case should be such that the in- 
fluence of compression, or any other phenomenon, acting by con- 
tiguity, would be completely eliminated. Kow, gentlemen, in the 
présent state of the science, the cases which include ail thèse con- 
ditions are extremely rare, so far, at least, as my knowledge goes. 
We may, however, mention as approximating to this idéal, the cases 
which were presented by L. Tiirck to the Academy of Sciences of 
Vienna,^ to which I hâve already alluded. They were four in number. 

In the instances recorded by L. Tiirck, there had been, gentle- 
men, either old hremorrhagic foci, then represented by ochreous 
cicatrices, or ramollissement foci arrived at the stage of cellular 
infiltration. In ail the cases, the hemiplegia resulting from the 
présence of foci had disappeared long before death, but the hemian- 
sesthesia had persifeted until the fatal end. The portions of the 
encephalon aff'ected by the altération are carefully mapped out. 

The German nomenclature of the différent parts of the encephalon, 
however forbiddiug it seems to us, on account of its multiplicity 
of strange terms, yet présents in my opinion, an incontestable advan- 
tage, that, namely, of supplying a very complète topographical map, if 
I may make use of the comparison, where the smallest hamlet receives 
a name. The French nomenclature has, no doubt, the advantage 
of tending to simplification, but this is sometimes to the détriment of 
absolute exactness ; it is often incomplète.. INTow, with respect to 
the question which occupies us, there is no détail, however minute, 
which ought to be neglected. We must, at ail hazards, take heed 
of the slightest détails, for we are quite ignorant, in the actual state 
of the science of the brain-physiology, wliether some little point, 
which has no name in the Trench nomenclature, may uot be a 
position of primary importance. 

Availing ourselves, therefore, of the nomenclature in use* beyond 
the Ehine, let us endeavour to become familiar MÏtli the topo- 
graphy, in order that we may accurately recognise the seat of the 
lésions, in the observations recorded by L. Tûrck. 

I place under your observation, a frontal section taken across 
the cérébral hémisphère?, immediately behind the corpora mammil- 
laria (Eig. i8). You recognise on this section, just exterior to the 
middle ventricles, the nucleus eaudatus (or intra-ventricular 

^ ' Sitznngsber. dcr Kais. Akademie der Wissenscbaftcu zu Wien,' 1859. 
V. infra, the analyses of tliese cases. 



256 



TOPOGEAPHY OF EXCEPHALIC LESIONS. 



nucleus of the corpus striatum), whichj in this région, is 
merely representcd by a very small portion of grey matter, 
— beneath and interior to it, the ojotic thalamus, hère largely 
<leveloped ; external to this h'es the capsula interna, formed princi- 
pally by bands of white substance which are simply the prolonga- 
tions of the lower stage of the crura cerebri ; thèse proceed to ex- 
pand in the centrum ovale to assist in constituting the corona 
radiata ; — external to this is the extra -ventricular omœleus of the 
corpus striatum, in which you distinguish tliree secondary nuclei 
denominated by the numbers 1,1, 3; the third, or outermost, is 
sometimes designated by the term putamen. Still more external is a 
thin lamina of white matter, the capsula externa, and finally, a small 
band of grey substance, the rampart (or claustrum) {Vormaner).^ 




TiG. iS. — Transversal section of brain, — a, optic thalamus ; — b, corpus striatum, 
Icnticular nucleus; — c, corpus striatum, caudate nucleus ;—/, indication 
of the radiating corona of lleil ; — 2, 2', 2", apopleetic foci (Obs. ii, in 
' Tiirck's Memoir,' v. hifrà, pp. 258-9) ; — 3, vestige of an apopleetic focus 
(Obs. iii, in 'Tiirck's Memoir '). 

Now, gentlemen, in the cases recorded by Ilerr Tiirck, the lésions 
had invadcd alike the superior and external portion of the optic 
thalamus, the third nucleus of the extra-ventricular portion of the 

^ The vormauer of Germân anatomists, the avant-mur, rempart, or noyau 
ruhané of the Trench, is a band of grey matter which, arising from the 
superior portion of the amygdala, curvcs round towards the white substance of 
the convolutiou bounding the fissure of Sylvius. (S.) 



OBSERVATIONS OF TURCK. 257 

corpus striatum, the superior portion of the capsula interna, the 
corresponding région of the radiating corona, and the adjacent white 
substance of the posterior lobe. 

We hâve consequently complex lésions to deal with hère, but they, 
at ail events_, allow the région which requires investigation, to be 
circumscribed. Purther researches, when sufficiently numerous, 
will enable us soon to ascertain the fundamental lésion, to which 
the existence of the hemiantesthesia should be attributed. 

Some other cases of hemiansesthesia, of cérébral origin, whicK 
hâve been published siuce those of Tiirck appeared, testify to lésions 
occupyiiig the same circumscribed région of the encephalon ; they 
make, however, no important additions to the results obtained by 
that observer. Such, amongst others, is the case recorded by Dr. 
Hughlings-Jackson,^ — hère again the altération was not confined 
to the thalamus ; it extended to the extra-ventricular nucleus of the 
corpus striatum, and consequently the capsula interna must hâve 
been affected in its posterior portion. It was the same in the case 
described by M. Luys^, the médian centre of the optic thalamus 
was affected, but the altération had invaded the corpus striatum, 
(probably the extra-ventricular nucleus). 

To recapitulate, we may conclude I believe from what précèdes 
that, in the cérébral hémisphères, there exists a complex région, 
lésion of which détermines hemiauaesthesia ; the limits of this 
région are approximately known, but, at présent, localisation 
cannot be carried any further, and no one lias a right to say that 
in the région in question, the optic thalamus should be inculpated. 
rather than the capsula interna, the centrum ovale, or the third 
nucleus of the corpus striatum. 

Up to the period in which we write, ansesthesia of gênerai sensi- 
bility alone appears to hâve been observed, as consécutive on an 
altération of the cérébral hémisphères, so that ohiiuhïlatlon of the 
spécial sensés would remain as a distinctive characteristic of hysterical 
hemianajsthesia. But, it may be doubted whether the organs of 
thèse sensés hâve been attentively explored in the cases of liemi- 

' The disease was uot strictiy limitée! to the tluilanius . . . Outwards the 
disease extended through the small tongue of corpus striatum wiiich curves 
round tlie outside of the thalamus, and thence up to the grey matter of the 
convolutious of the Sylviau fissure. (' London Hospital Reports,' loc cil., 
t. iii,p. 376.) 

- Luys, ' Iconographie photographique des centres nerveux,' p. 16. 

17 



258 DESIDERATA. 

ansesthesia of cérébral origin, hitlierto publislied ; tlie records are 
sileut with respect to it.' 

^ At the period when this Lecture was delivered, we were only acquainted 
with the observations of L. Tiïrck by the brief mention made of them iu 
Rosenthal's ' Treatise on Diseases of the Nervous System.' Since then, thanks 
to the courtesy of M. Magnan, we hâve been enabled to procure the complète 
translation of Turck's meraoir ('Ueberdie Beziechung gewisses Krankheit- 
sherde des grossen Gehirnes zur Anasthesie,' Aus dem xxxvi Band, S. 191, 
des Jahrganges, 1859, des Sitzungsberichte der Mathem. Naturw. Classe der 
Kais. Akaderaie der Wissenchaften). We thiuk it useful to give the substance 
of this work. After recalliug the fact that, usually, in hemiplegia caused by the 
formation of apoplectic foci in the brain (hsemorrhage and ramollissment), 
the sensibility re-appears very promptly as a gênerai rule, the author relates 
four cases where, on the contrary, the anœsthesia persisted in a higli degree of 
intensity. 

Case i. — Fr. Amerso, set. 18. In August, 1858, left hemiplegia, speedy 
re-appearance of motor power. i2th Nov. — The movements of the left 
upper extremity are rapid and energetic; those of the corresponding inferior 
extremity exhibit slight paresis. Very intense anresthesia exists on the left 
side (limbs, body, &c.). Facial sensibility is diminished, on this side only. For- 
mications from time to time through ail the left side. Died, i8th March, 
1859. 

Âulopsy. — At the base of the corona radiata of the riglit hémisphère, imme- 
diately outside of the tail of the corpus striatum, appears a lacuna of the size 
of a pea {cellular infiliratmi) . The anterior wall of this lacuna is two Unes 
behiud the anterior extremity of the optic thalamus. Two or tbree Unes far- 
ther off, another lacuna is seen, of smaller dimensions, which extends to four 
or fîve Unes behind the posterior extremity of the thalamus, so that as the usual 
leugth of the optic thalamus is eighteen Unes, the portion of the corona radiata 
which lies immcdiately adjacent to the tail of the corpus striatum was 
perforated, fore and aft, by the old focus of ramollissement for au extent of 
eleven Unes. A similar focus iuvolves the external portion of the third part of 
the lenticular nucleus. It commences ncarly two Unes behind the anterior 
border of the optic thalamus and ends at about four Unes from the posterior 
extremity of the optic thalamus. In its course of one inch long, it occupied 
the'greater lengtli of the internai side of the third part of the lenticular 
nucleus, and part of the capsula interna. In the posterior half of their 
course, then two foci were not farther part, in one place, than the distance of 
one Une. It follows, that in this place, almost ail the corona was separatcd 
from the internai capsule aud the optic thalamus. Spinal cord. — Collection of 
granular bodics somewhat abundaut in the left latéral coluinu, rare in the 
anterior columu. 

Case 2, S. J — , œt. 55. — Apoplectic attack, foUowed by heiui])lcgia, Oct. 25, 
i8rti. Two months after, the paralysis of the extremitics disappcared to such an 
extent that the patient could cxtend the arms, grasp objccts with some strength, 
and walk without hclp, but lamcly. Ocl., 1855. — Anœsthesia of the left 



DESIDERATA. 259 

Tor my own part, I am inclined to believe tliat tlie participation 
of tlie spécial sensés will be one day recognised, when care shall 

extremities (face aud body also beuunibed, but in a less degree) persisting 
since tlie attack. Power of motion recovered, but the limbs of the left side 
are more feeble tlian tliose of the right. Died, Oct. 31, 1858. 

Autopsij. — Old flat cicatrix, about five lines in breadth and eight in length, 
situated at the superior and external part of the right optic thalamus. The 
cicatrix begius four aud a half lines behiud the left auterior extremity of the 
optic thalamus, and ends eight lines farther off. Lying parallel to this cica- 
trix is another, an iuch long, occupying the third part of the lenticular nucleus ; 
it begius two lines behiud the auterior extremity of the thalamus, and ends 
nearly three lines in front of its posterior extremity (figs. 18, 2, aud 2'). There 
was, besides, a lacuna in the right inferior lobe (flgs. 18, 2"), another in the 
anterior lobe of the same side, two as big as a pin's head in the auterior part 
of the right optic thalamus ; two in the pons Varolii, and finally, one in the 
right and superior portion of the left hémisphère of the cerebellum. No 
secoudary degeueratiou of the cord was observed. 

Case 3.— Fr. Hasvelka, œt. 22. November ist, 1852. Apoplectic 
attack, hemipiegia on the right, with intense anœsthesia of the correspouding 
Lalf of the body. At the end of five weeks, diminution of motor-paralysis. 
leb. 3, 1S53. — Motion quite free, on the right side. The eutire right half of 
the body is the seat of very marked anœsthesia (scalp, ear, face, and body). 
The ansesthesia is equally noticeable in the eye-lid, uostril, left half of the 
lips, and uot only ou the outer but also on the inner side. The right conjunc- 
tiva is less seusitive than the left. When the right nostril is tickled, the 
sensation is less felt than in the left. Same différence between the right 
nieatus auditorius, and the left. In the right half of the mouth (tongue, 
palate, gums, cheek), the sensation of beat is less vivid than in the left. At the 
lip of the tongue on the right, and over the space of au inch in length, the 
patient does not feel the taste of sait. Same resuit as regards the right half 
of the dorsum and root of the tongue. On the right also, the sensé of smell 
is weakened, and vision is less distinct. When the pupils hâve been made to 
contract by bringiug a light close to the eyes, the right pupil afterwards dilates 
more than the left, the sensé of hearingis normal on both sides. Fcbruary 26. — 
The ana;sthesia has diminished ; the movements are more energetic. Mardi 15. — 
Temporary improvement of vision; no différence between the two eyes. 
April 3. — The anaesthesia still exists over the right half of the body (on touch, 
and pinching). Dcbility of vision augmeuted on the right. Died April 4. 

Auiopsij. — In the white substance of the left superior lobe, is found a focus 
of ramollissement two iuclies in length and one in breadth. It dipped into the 
inferior couvolutions of the operculum, and attained the surface of the brain. 
Its posterior extremity corresponded to that of the optic thalamus ; its anterior 
part greatly exceeded that of the thalamus. In its broadest portion, the focus 
was only separated by three lines from the tail of the corpus striatum. The 
couvolutions lyiug beueath, were to the extent of a florin, ycllow, softeued, 
aud depressed. (Fig. 18, 3.) Optic thalamus healthy, perhaps a little frag- 



260 DESIDERATA. 

have beeii taken to seek for it. My opinion is founded on tlie fol- 
lowiug basis. 

There exists in the clinical history of the organic diseases of the 
nervons centres a symptomatic sign but little knovvn, and little re- 
marked as yet, which I shall liave occasion some day to discuss in 
détail before you. This is a kind of rhythmical convulsion whicli 
occupies an entire half of the body, including the face, (in many 
instances at least), and which assumes soraetimes the appearance of 
the clonic jerking of chorea, sometimes that of the tremor of para- 
lysis agitans. This hemilateral trembling occasionally présents itself 
as a primary affection ; at other times, it supervenes consecutively 
on a hemiplegia, whose invasion was sudden. In the latter case, it 
commences to appear at the epoch when motor paralysis begins to 
improve. The lésion consists in the présence either of a focus of- 

meut of the third part of the leuiicular uucleus has been touchcd. The focua 
liad destroycd a soinewhat considérable leiigih of white substance, and the two 
external thirds of the foot of the coroua radiata. Spinal Cord. — Slight agglo- 
mération of nuclei in the most posterior part of the latéral column. 

Case IV. — Anne B — , au aged woman, died 22nd February. For many 
years she had right hemiplegia, with intense ansesthesia of the sanie side. lu 
addition, sensorial ansesthesia (sight, smell, taste) of the same side, and-' 
formications. 

Autopsy. — Old apoplcctic focus, pigmented brown, situai ed along the outer 
part of the left optic thalamus, and quite close to the tail of the corpus stria- 
tum. It commences six lines behiud the auterior extremity of the thalamus 
and extends two or three lines in front of its posterior extremity. Anteriorly, 
it is half a line, and posi.eriorly two or three lines bcneath the superior 
surface of the thalamus, which is considerably depressed in this direction. Aa 
inch long and four or Cve lines deep, the focus touches a large extent of the 
posterior part of the radiation of the crus cerebri, a part of the internai 
capsule, aud, perhaps, a part also of the lenticular nucleus. Spinal Cord. — 
Accumulation of granular bodies in the posterior part of the right latéral 
column. 

To sum up : the foci were seated at the external periphery of the optic thalami, 
they extended, from before backwards, in the longitudinal axis of the cerebrum, 
without, in most cases, rcaching the cxtrcmitics of the thalamus. They werc 
t'rom eiglit lines to an inch in length, rcaching evcn two inches into the white 
substance. The régions affected were : the superior and external part of the 
thalamus ; the third part of the lenticular nucleus ; the {josterior part of the 
internai capsule, compriscd between the thalamus and the lenticular uucleus ; 
the corresponding portion of the white substance of the superior lobe opposed 
to it. Several of thèse régions werc always affected togethcr. The libres 
which procced from the white substance of the hémisphère into the external 
part of the optic thalamus werc constuutly affected. 



HEMIANiESTHESIA AND CEREBEAL LESION. 261 

liœmorrliage or of ramollissement, or in tliat of a tumour. In ail 
cases of this kind which I hâve hitherto observed, and in the 
analogous facts collectcd frora varions antliors, the lésion iu ques- 
tion occupied the posterior région of the optic thalamus and the 
adjacent parts of the cérébral hémisphère exterior to it. 

No\r, hemianccsthesia is a tolerably common — but still not a 
constant — accompaniment of this group of symptoms, and it 
occupies the same side of the body as the tremor.^ 

It existed in a high degree of development, in a maie patient 
whose history M. Magnan lias recently communicated to the Société 
de Biolofjh ; in his case, the form of tremor of which I hâve tried 
to give you a summary notion, showed itself in a most marked 
manner. Everything tends to show (I cannot be more positive 
as there w\is no autopsy) that the encephalic lésion was, in this 
man, of the same sort, with respect to position, as that which I 
found in my patient. Now^ in this case, M. Magnan ascertained, 
in the clearest manner, that tactual sensibility was not alone involved ; 
the spécial sensés were themselves afTected, as they are in hysterical 
hemianœsthesia. On the side stricken with hemianœsthesia, the eye 
was afFected with amblyopia, the sensé of smell was lost, and 
taste was completely abolished. 

Heuce, it becomes probable, if I am not mistakeu, that complète 
hemianagsthesia, with dérangements of the spécial sensés, — aud con- 
sequently, such as is presented in hysteria, — may, in certain cases, 
be produced by a circumscribed lésion of the cérébral hémisphères.- 

' See a Lecture of M. Charcot (in ' Le Progrès Médical,' 23 Janvier, and 
6 Tevrier, 1875), on 'Hemicborée post-hémiplégique.' (Note to snd édition.) 

" Tlie views expressed iutliis Lecture, relative to liemianœsthesiaof cérébral 
origin, hâve received further clinical confirmation from the incidents of a case, 
-which we noted, in M. Charcot's wards. ('Progrès Médical,' 1S73, p. 244), 
and from the experiments on animais conducted by M. Veyssière ('Recherches 
cliniques et expérimentales sur l'hemiancsthesie de cause cérébrale,' Paris, 
1874). This work also contains. some interesting clinical notes. (Note to the 
2nd édition.) 



LECTUEE XI. 

OVAEIAN HYPER^STHESIA. 

SuMMARY. — Local liynteria of British authors. Ovarian pain ; Us 
frequency. Kistorical remaries. Opinion of M. Brifptet. 

Characters of ovarian hyper œsthesia. lis exact position. 
Aura hysterica : first node ; glohus liystericus, or second node ; 
cephalic phenomena or third node. The starting -point of the 
first node is in the ovary. Lésions of the ovary ; desiderata. 

Relations between ovarian hyper œsthesia and the other acci- 
dents qf local hysteria. 

Ovarian compression, lis infl^tence on the attachs. Modus 
operandi. Ovarian compression as a means of arresting orpre- 
venting hysterical convulsions hioivn informer times. Its appli-. 
cation in hysterical épidémies. Ejndemic of St. Médard — the 
remedy termed " secours.'" Analogies which exist letween the 
arrest of hysterical comndsions ly compression of the ovary, and 
the arrest of the aura einleptica hy ligature of a limh. 

Conclusion, from a therapeutical point of vieiv. Clinical 
observations. 

Gentlemen, — By the somewhat picturesque and certainly very 
practical term local hysteria, British authors are accustomed to 
designate most of the accidents which persist, in a more or less 
permanent manner, in the intervais between the convulsive fits of 
hysterical patients, and which aluiost always enable us, on account 
of the characteristics they présent, to recognise the great neurosis 
for what it really is, even m the absence of convulsions. 

nemlanasthesia, jiaralysis, contracture, fixed pah fui points occu- 
pying différent parts of the body (rachialgia, pleuralgia, clavus 
hystericus), according to this définition, come under the head of 
local hysteria. 



OVAEIAN PAIN. 263 

I. 

Among tliese symptoms there is one which, on account of tlie 
prédominant part it, in my opinion, plays in the clinical liistory of 
certain forms of hysteria, seems to me to deserve your entire atten- 
tion. I refer to the pain which is felt in one side of the abdomen, 
especially in the left, but which may occupy both sides, at the 
extrême limits of the liypogastnc région. This is the ovarian pain, 
concerning which I said a few words in my last lecture ; but I do not 
wish to make unreserved use of this term before justifying, the hypo- 
thesis which it imphcitly adopts — and this, I trust, will be an easy task. 

This pain I shall enable you to touch, as it were, with the finger, 
in a few moments, and to observe ail its characteristics, by intro- 
ducing to your notice five patients who constitute almost the whole 
of the hysterical cases, actually existing among the i6o patients 
who occupy the department devoted in this hospital to women 
affected by incurable convulsive diseases, and reputedly exempt 
from mental aliénation. 

II. 

You already perceive, from this simple indication, that ihac pain 
is a fréquent symptom in hysteria ; this is a fact long recognized 
by-the majority of observers. 

Let it sufîice, as regards former times, to mention the names of 
Lorry and Pujol, who, most particularly, noticed the existence of 
hypogastric and abdominal pains, in hysterical cases. 

It is singular, after this statement, to find that Brodie who was 
perhaps the first to recognize ail the clinical interest which attaches 
to local hysteria, does not treat of abdominal pain in a spécial manner^. 

It seems as of traditional custom that the practical spirit of 
English surgeons should be attracted by the clinical difficulties 
which the local symptoms of hysteria preseiit. Mr. Skey who, in 
this respect, may be regarded as continuing Brodie's work, in a very 
interesting séries of lectures on local or surgical forms of hysteria,^ 
as he calls them, expatiates on the iliac pain, or pain of the ovarian 
région, which, in his opinion, is very common, and which, accord- 
ing to his view, but contrary to what really occurs, is chiefly met 
with in the right side. 

^ Brodie, ' Lecture illustrative of certain nervous affections,' 1S37. 
" E. C. Skey, 'Hysteria. — Local or Surgical forms of Hysteria,' six lec- 
tures, London, 1870. 



264 OVARIAN PAIN. 

You are aware that, in Prance, Schutzenberger, Piorry, and 
Négrier, hâve laid spécial stress on this symptom, which they un- 
liesitatingly attribute to the abnormal sensibility of the ovary. 

In Germany, Eomberg bas followed Schutzenlierger on this topic ; 
however, it is to be remarked that, as regards our contemporaries, 
most of the German authors pass in almost complète silence ovcr ail 
tbat relates to this hypogastric pain. This is the case, for instance, 
with respect to Hasse and Valentiner. Hence, it is clear that this 
symptom, after having enjoyed a certain degree of favour, doubtless 
on account of the theoretical considérations connected with it, bas 
■gone somewhat ont of fashion, at présent. 

Symptoms, also, as you sce, hâve their destiny : Ilahent sua 
fata. I should not be surprised if the otherwise very legiti- 
mate influence of M. Briquet's work counted for a good deal in 
the production of this resuit. It now becomes our duty to examine 
how far we ought to foUow this eminent author in the path which he 
has marked out for us. 

III. 

I am far from saying that M. Briquet did not recognise the very 
fréquent existence of fixed abdominal pains in hysterical cases. He 
has even coined a new word to designate thèse pains calialgia (from 
KoiXia, the belly), and a word, even though it be merely a word, is 
still something that arrests the mind. In 200, out of 430 cases 
of hysteria M. Briquet met with cœlialgia. However, I should point 
out to you that, under this name, he includes alike the pains of the 
upper part of the abdomen and those of the iliac and hypogastric 
régions, but the latter are confessedly the most common. 

At first glance, therefore, it seems as if the différence between 
M. Briquet and his predecessors were merely an apparent one. 
Now, it is nothing of the kind, and hère is the chasm which divides 
them. 

Whilst MM. Schutzenberger, Piorry, and Négrier place in the 
ovary the chief seat — the focus, so to speak — of the iliac pain, M. 
Briquet only admits the existence of a simple muscular pain, an 
kystcncal mi/odj/nia. According to his view: 1°, pain of the pyra- 
midalis or of the lower extremity of the rectus abdominis has been 
mistaken for utérine 2oain ; 2°, pain of the lower extremity of the 
obliquus abdominis takes the place of the so-called ovarïan jjain. 
Such is the thesis of M. Briquet. 



OVAETAN PAIN. 265 

IV. 

Let us investigate togetlicr, gentlemen, the basis on wliich tliis 
opinion rests. In order to arrive at our object, I am about to refer 
to tbe observations which I bave been enabled to coUect upon a large 
scale in this hospital. I shall, therefore, proceed to describe this 
pain, sucli as I bave learned to know it, 

i^. Sometimes it is an acute, nay, a very acute pain; tlie patients 
cannot tolerate tbe sligbtest toucb, nor suffer tbe weight of the bed 
clothes, &c.; tliey sbrink suddenly, and as if instinctively, from tbe 
finger of tbe investigator. Add to tbis a certain degree of tumé- 
faction of tlie abdomen, and you bave tbe clinical appearance of 
false peritonitis — tbe spurious peritoiùtls of Britisb autbors. It is 
manifest tbat tbe muscles and tlie skin itself sbare in tbe suffering 
hère. The pain tben occupies a considérable exteut of tbe surface of 
the body, and, consequently, is not easily localised. However, Todd^ 
remarks, and I bave frequently verified tbe accuracy of bis state- 
ment, that in certain cases, a circumscribed cutaneous hypertesthesia 
occupies a rounded dermal space, of from two to tbree incbes in 
diameter. Tbis hypersesthesia has its seat partly in tbe bypogastrium, 
partly in the iliac fossa, and corresponds, according to tbis author, 
to the région of the ovary. 

2°. In otber cases, the pain does not spontaneously show itself; 
it re([uires pressure to discover it, and, under such circumstances, we 
note the following phenomena : a, there is gênerai anœstbesia of the 
shin; h, the muscles, if relaxed, may be pinched and raised without 
causing pain ; c, tbis preliminary exploration proves that tbe seat of 
tbe pain is neither in the skin nor in tbe muscles. It is conse- 
quently necessary to push the investigation further, and by ]:)ene- 
trating, as it were, into the abdominal cavity by pressure of the 
fingers we reach tbe real focus of the pain. 

This opération allows us to make certain that the seat of the pain 
in question is usuaDy fixed, that it is always nearly the same; and 
indeed, it is not uucommon to find tliat patients point it out, with 
perfect unanimity. Prom a line uniting the anterior superior spines 
of the ilia, let fall the perpendicular lines which form the latéral 
limits of the epigastrium, and at the intersection of thèse vertical 
and horizontal lines will be found the focus of pain, as indicated by 

' Todd, 'Clinical Lectures ou tlie Nervous System.' Lecture xx, p. 448, 
London, 1856. 



366 AUEA HYSTERICA : NODES. 

the patient, and wliicli becomes further manifest on pressure being 
applied by the finger. 

Deep exploration of this région allows us readily to recognise 
part of the superior inlet which describes an inwardly concave 
curve; this is our guiding point. Towards the middle part of this 
rigid crest, the hand will usually meet with an ovoid body, elongated 
transversely, which, when pressed against the bony wall, shps under 
the fingers. When this body is swollen, as often happens, it may 
attain the size of an olive, or of a small egg, but with a little ex- 
périence its présence can be easily ascertained, even when it is of 
much smaller dimensions. 

It is at this, the period of exploration, that the pain is chiefly 
determined ; it then manifests itself with characters which may be 
called speàfic. This is no common pain we hâve to do with, but a 
complex sensation which is accompanied by ail, or some, of the 
phenomena of the aura hystenca ; such as they spontaneously show 
themselves before an attack. When the sensation is thus determined, 
the patients recognise it as familiar, — as having felt it scores of 
times. 

In short, gentlemen, we hâve succeeded in circumscribing the 
initial focus of the aura, and, by the same act, we hâve provoked 
irradiations in the direction of the epigastrium {i\\Qjirst node of the 
aura, to use M. Piorry^s terminology) sometimes complicated with 
nausea and vomiting ; then, if the pressure be continued, there soon 
supervene palpitations of the heart, with extrême frequency of the 
puise, and fînally, the sensation of the globus hystericus is developed 
in the throat {second node). 

At this point terminâtes the description, given by authors, of the 
ascending irradiations which constitute the aura hysterica. But, 
judging from my own observations, the enumeration of sym])toms, 
if thus limited, would be incom])lete ; for an attentive analysis allows 
us to ascertain the présence, in most cases, of certain cephalic dis- 
orders which are evidently the continuation of the same séries of 
phenomena. Such are, for instance (in case of compression of the 
left ovary) , the intense sibilant sounds in the left ear, which the 
patients com])arc to the strident noise produced by the whistle of a 
railway engine — a sensation as of blows from a hammer falling on 
the left tem])oral région, — and, lastly, a marked obnubilation of sight 
in the left eye. 

The same phenomena show themselves in the corres])ondiiig parts 



AUKA HYSTEEICA : CEPHALIC STMPTOMS. 267 

of tlie right side, when pressure is applied on exploration of tlie right 
ovary. 

The analysis cannot be carried further, for when matters hâve 
arrived at this point, consciousness becomes profoundly affected, and. 
in their confusion, the patients no longer retain the faculty of de- 
scribing \vhat they feel. Besides, the convulsive fit soon supervenes, 
if the experiment be persisted with. 

Leaving out of the question the phenomena which relate to the 
last phase of the aura hysterica (the cephaUc si/mj^toriis) , I hâve just 
been describing to you, gentlemen, the whole séries of phenomena 
obtained in the experiment of Schutzenberger, and we are thus led 
to acknowledge, with this eminent observer, that compression of 
the ovarian région, simply reproduces artificially the séries of sym- 
ptoms that spontaneously présent themselves in the natural course 
of the disorder. 

I am well aware that, according to M. Briquet, the aura 
hysterica starts, in the immense majority of cases, from the 
epigastric node ; neither do I forget that, in support of his asser- 
tion, this author quotes au imposing array of figures. But we 
must not always bow to statistics, and it may be fairly asked 
whether M. Briquet, who lias shown himself somewhat severe 
upon the " ovarists," lias not in his turn allowed himself to be 
carried away by some préoccupation which made him neglect to 
inscribe the initial iliac pain in the séries of phenomena of the 
aura. 

If I am to judge from my own observations, this iliac pain always 
précèdes in point of time, however small the interval may be, the 
epigastric pain, in the development of the aura, and consequently 
it constitutes the first link of the chain. 

V. 

It remains for me, gentlemen, to establish that this particular 
point, where the iliac pain of hysterical patients résides, corresponds 
exactly with the position of the ovary, then I shall hâve rendered 
it highly probably, if not absolutely demonstrated, that the painful 
oval body, whence the irradiatious of spontaneous or provoked 
hysteria start, is really the ovary itself. 

Generally, I believe, an imperfect idea is formed of the précise 
position which the ovary occupies duriiiglife. When, the abdomen 
being laid open, and the intestines raised, we find in the pelvis 



26S POSITION OF OVAEY. 

behind the utérus, in front of the rectum, the appendages of the 
utérus flabby, shrunken, and as it were shrivelled, it is plain that we 
are in présence of appearances not at ail answering to vital con- 
ditions. It is évident that, after deatli, the arterial network of the 
Tallopian tubes and of the ovaries (the vascular wealtli and erectile 
properties of which hâve been so well illustrated by my frieud Pro- 
fessor Rouget, of Montpelier), has long ceased to fulfil its func- 
iions. Again, it must not be forgotten that the laying open of the 
abdomen most certaiuly alters the true relations of the appendages 
of the utérus to other parts. This is proved by the fact that, in 
frozen corpses,i the ovaries occupy a more elevated position, — one 
which recalls to some extent their admitted position in the new-born 
infant. In the diagram before you, which is copied from the ^ Atlas' of 
M. Legendre, you see a horizontal trans verse section of the body of a 
woman, aged 20 ; its plane passes three quarters of an inch (2 centi- 
mètres) above the pubis, and divides one of the ovaries in twain, 
Avhilst the other, lying superior to it, escapes. From this it appears 
that, in the adult female, the ovary should be situated on a level 
with or even a little above the superior inlet, (or brim of the pelvis) 
jutting over into the iliac fossa along with the Fallopian tube. This 
resuit accords in every particular with that given by palpation 
applied to the living body. I will add that if you pass a long 
needle perpendicularly through a corpse laid on the dissecting table, at 
a spot corresponding with that where hysterical patients complain of 
ihac ])ain, you hâve every chance — as I hâve frequently found — of 
"transfixing the ovary. 

This position of the ovary appears, in fact, to hâve been im- 
plicitly recognised by Dr. Chéreau in his excellent treatise on 
diseases of the ovary,2 when he remarks that, in women, where 
the abdominal wall does not ofier too great a résistance the tumé- 
faction, or even the sensibility only, of the ovary may be ascer- 
tained. The introduction of the'finger into the rectum would not be 
a superior mode of exploration, accordiiig to our author, except 
in cases where the abdominal parietes présent an invincible 
obstacle. 

Gentlemen, after ail thèse explanations which I hâve just discusscd, 
I believe I havc a riglit to draw the conclusion that it is to the 

' E. Q,. Legeudre, 'Analomie Chirurgicale homolograpbique,' &c., pi. X, 
Paris, 1858, 

^i'CLéreau, 'Etudes sur les maladies dcj'ovaire,' Paris, 1841. 



HYSTEEICAL OVAETA. 26Ô 

ovary, and the ovarij aloyie, we must attribute Ûiefixed iliac pain of 
hysterical patients. It is true, that at certain epochs, and in severe 
caseSj the pain, by a mechanism which I need not at présent indi- 
cate, extends to the muscles and to the skin itself, so as to justify 
the description given by M. Briquet ; but I cannot too often repeat 
that, if liinited to thèse external phenornena, the description would 
be incomplète and the true focus of the pain misapprehended. 

VI. 

This would be the place to investigate what is the anatomical con- 
dition of the ovary in cases where it becomes the seat of tlie iliac 
pain of hysterical patients. In the actual state of afïairs, we 
can unfortunately ouly give you some rather vague information, 
in référence to this subject. There occasionally exists a more 
or less marked tuméfaction of the organ, such as was found in 
the case of blennorrhagic ovaritis recorded in the memoir of M. 
Sclmtzenberger. But this is rather an exceptional circumstance, 
and it is proper to remark that common inflammation of the ovary 
may exist with ail its cliaracters, and yet there shall supervene no 
irradiations, as described, neither spontaneously nor under the 
influence of pressure. M. Briquet has not failed to set this circum- 
stance proniinently forward, and hère he is perfectly right. Hence 
we must eraphatically déclare that every ovarian ivfamwation is 
not indifl'erently adapted to provoke the development of the aura 
hysterica. Ovarian tuméfaction in hysterical patients is sometimes 
completely absent, at other times it is but little marked ; and it 
seems probable enough that the tuméfaction of the ovary^ in such 
cases, is the resuit of a vascular turgescence analogous to what is 
exhibited after the occurrence of certain neuralgic affections. Patho- 
logical anatomy has not hitherto supplied us with any positive data 
in relation to this question ; at présent, therefore, you may designate 
the state of the ovary either by tlie term liyperlànesls (Swe- 
diaur), or ovarialfjia (Sclmtzenberger), or ovaria (Négrier), — the 
name, indeed, matters little, when the fact is well established. 

YII. 

It being conceded that the ovary is the starting-point of the 
aura hysterica, at least in a group of cases, it will not be uuiu- 
teresting now to show that an important and, in some sortj an iiiti- 



270 HYSTEEICAL OVAEIA. 

mate relation exists between tlie ovarian pain and the otlier plieno- 
mena of local hysteria. 

You can in fact discern, gentlemen, in the patients to whom I 
•call jour attention a remarkable concord between the seat of the 
iliac pain and the manner in which the concomitant sjmptoms are 
localised. I will not revert to the cephalic phenomena of the aura 
which, as I stated a little ago, are manifested o]i the same side with 
the ovarian pain ; I will confine myself to showing that the /lemd- 
anaslkesia, the paresis, and the contracture of extremities, occupy 
the left side when the avaria is situated on the left, and vice 
versa. I will also point ont to you that when the ovarian pain 
■occupies both left and right sides, the other phenomena become 
bilatéral, predominating however on the side where a greater in- 
tensity of iliac pain is felt. 

On several occasions, we hâve noted in some of our patients an 
abrupt change of the seat of ovarian pain. The patient Ler — is 
one of thèse. When the ovaria', in her case, predomiuated in the 
left side, the cephalic symptoms of the aura, the contracture of ex- 
tremities, &c., showed, for the time, their maximum of development 
■on the same side, — predominating afterwards on the right side, 
when the right ovary became again the more painful. 

It must not be forgotten that ovarialgia appears to be a con- 
stant phenomenon, one eminently permanent, in the form of 
hysteria which engages our attention, so that, taken in connection 
with some other indication of the same category, it may guide 
your diagnosis in difficult cases. 

YIII. 

It remains for me now, gentlemen, to enter upon an exposition 
of facts which will probably be considered by you as the main 
feature of this study. Thèse facts, in reahty, are of a nature, if I 
€rr not, to set ont in still greater prominence the truly prédominant 
part pertaining to ovarialgia in one oftheforvis of JiJ/steria. 

You hâve just seeu how methodical compression of the ovary 
can détermine the production of the aura, or sometimes even a 
perfcct hysterical seizure. I jn'opose now to show^ you that a more 
■energetic compression is capable of sioppiug the devcloj)mcnt of the 
attack when beginning, or even of cutting it short when the évolu- 
tion of the coiivulsive accidents is more or less advanced. This, at 
least, is whai you can very plainly discern in two of the patients 



OVARIAN HYSTEEIA. 271 

wliom I liave placed before you. In their cases, tlie arrest of 
the convulsion, wlien compression has been properly applied, is 
total and final. In the others, the manipulation merely modifies 
the phenomena of the seizure in varying degrees, without however, 
producing complète cessation. And be kind enough to note care- 
fully that we hâve to deal in ail of them, not with common vulgar 
convulsive hysteria, if I may so express myself, but with convulsive 
hysteria in what is uuanimously recognised as its gravest type — I 
mean hystero-einlepsy. 

Let us suppose that one of thèse womeu is taken with a seizure. 
The patient suddenly falls to the ground, with a shrill cry ; loss of 
consciousness is complète. The tétanie rigidity of ail her members, 
which generally inaugurâtes the scène, is carried to a higli degree ; 
the body is forcibly bent backwards, the abdomen is prominent, 
greatly distended, and very resisting. 

The best condition for a perfect démonstration of the efîects of 
ovarian compression, in such a case, is that the patient should be 
laid horizontally in dorsal decubitus, on the floor, or, if possible, 
on a mattress.i The physician then, kneeling on one knee, presses 
the closed hand or fist into that iliac fossa, which he had previously 
learned to regard as the habituai seat of the ovarian pain, 

At first, he must throw ail his strength into the effort in order to 
vanquish the rigidity of the abdominal muscles. But, when this is 
once overcome and the hand feels the résistance ofî'ered by the rim 
of the pelvis, the scène changes and resolution of the convulsive 
phenomena commences. 

The patient soon begins to make numerous and sometimes noisy at- 
tempts to swallow j then consciousness returns almost at the same time, 
and now the woman either moans and weeps, complainmg that you are 
hurting her (as in the case of Marc — ) or else she expériences relief, 
and testifies her gratitude ; "Ah! c'est bien! cela fait du bien!" 
is always the cry of the patient Gen — , under such circumstances. 

Whichever happens, the resuit in short is always the same, and if 
you but continue the pressure for two, three, or four minutes, you 
are almost certain to find ail the phenomena of the seizure disappear 

1 It may not be amiss to remark that, if the seizure occur whilst the patient 
is l'cposing, the method of compressiou described can also be applied without 
removing her from the bed. Applied in this manner, by Profcssor Charcot, I 
hâve been a witness to its iustantaneous effect, iu the hysterical wards of La 
Salpôtrière. (S.) 



272 COMPRESSION OF THE OVAEY. 

as if by magie. You may, besides, vary the experiment and, at your 
pleasure, by removing the compression and again applying it, you 
can stop the seizure or allow it to recur as often ahuost as you like. 

When once we hâve definitely overcome the obstinate résistance 
which the abdominal parietes always offer at first, it is not necessary 
to employ ail one's strength, and the application of the two first 
fingers of the haud to the presumed seat of the ovary is sufficient 
to produce the desired eilect. However, the opération, if it require 
to be prolonged for some minutes, is always rather fatiguing to the 
physician. I bave contemplated modifyingthe modus operandi. 

Perhaps, you might make use of a bag filled with shot, such as 
M. Lannelongue has employed for a différent purpose, or the appli- 
cation of an appropriate bandage might be tried, — this is a question 
to be considered. At présent, the assistants in the wards who bave 
been instructed in the metbod of manipulation described, apply it day 
by day in the case of those patients to whom it is really bénéficiai. 

IV. 

It is singular enough, gentlemen, that a method the practice of 
which is so simple and which, undoubtedly, is capable of rendering 
real service, should bave fallen, as it has fallen in our days, into 
complète disuse. As I bave already intimated, the invention of this 
process is far from being m.y owu ; it may possibly be traced to a 
very ancient period ; it is certain tliat it dates from a time anterior 
to the sixteenlh ccntury. The foUowiug is what I hâve learned 
in référence to it, from some researches made rather hurriedly 
amongst the dusticst, and Iherefore the least frequentcd, volumes 
of my library. 

Willis, in the i7th century, in bis treatise on convulsive disease, 
expressed himself as follows : ' It is certain,' he says, ' that the con- 
vulsive spasm which cornes from the belly is arrested and can be pre- 
vented from ascending to the neck and head by a compression of the 
abdomen, determined by arms being clasped round the body, or by 
means of bandages drawn very tight.' Ile states also that he succeedcd 
himself in stopping a fit, by pressing energetically with both hands 
joined togetlicr u])on the lower part of the belly. But Mcrcado'-^ 
(in 1513) had long prcviously advised the use oï frictions on the 

^ Willis, ' De Morbis Convulsivis/ i. ii, p. 34. 

- D. L. Mcrcatus, ' Opéra, lit. iii, De virgiiiuiu et vidiuuum affcctionibus,' 
p. 546, riaucor, 1620. 



HISTOEIOAL SKETCH. 273 

abdomen, witli the object of reducing the womb, which he supposée! to 
be displaced, according to the old doctrine.^ One of his countrymen, 
Monartèsj it seems, went about it in a more determined manner, for 
he placed a large stone on the patientas belly, during the seizure. 

It does not appear, however, that this custom prevailed widelj ; 
for I do not find it mentioned in Laz. Rivière^ nor in F. Hoffmann. 
Boerhave alone, at the beginning of the i8th centurj, insists anew 
upon compression of the abdomen during the hysterical seizure ; 
it should be apphed, according to him, by means of a cushion placed 
under sheets drawn tight^ and extending from the false ribs to the 
crests of the ilia. In this manner, he says, you give almost certain 
relief to the patient, provided the sensation of the globus hystericus 
bas not yet ascended beyond the diaphragm.^ 

In modem times, Eecamier, reviewing this method, which, as you 
see, was already ancient, placed on the belly of the patient a cushion 
upon which an assistant took his seat. His example has been but 
little followed, so far as I am aware, except by Négrier_, the Director 
of the School of Medicine of Angers, whose ' Collection of facts 
relating to the history of the ovaries and of the hysterical aftections 
of females/ published in 1858, does not, however, appear to hâve 
attracted much attention. The process adopted by Négrier is a 
more methodical one than tliose employed by his predecessors ; in 
the application of compression, it is the ovary he aims at, ' a strong 
and broad pressure exerted by means of the hand upon the ovarian 
région is sufficient in many cases,^ remarks Négrier, ' to ward off 
and completely suppress the convulsive seizure.' 

Bat, let us put aside for awhile the methods of regular médical 
practice, and see what hâve been the processes by means of which, 
in certain celebrated hysterical épidémies, the assistants gave 
relief to the " convulsionnaires." Among the modes of succour 
adopted, we find mention made of one very curions custom well worth 
examining, the original notion of which must, in ail probability, hâve 
been owing to the suggestion of some " convulsionnaire " ; I allude to 
compression of the abdomen. There are, in fact, hysterical patients, 
who, on experiencing the premonitory pains of the aura, instinctively 
seek relief in compression of the ovarian région. Such is the case, 
for instance, as regards one of our patients, named Gen — , whose 

^ Négrier, " Receuil de faits pour servir à l'histoire des ovaires et des 
affections hystériques de la femme," Angers, 1858, pp. 158, 169. 
- Vau Swieten, ' Comra,,' t, iii, p. 417. 

18 



274 HYSTEEICAL EPIDEMICS. 

symptoms liave been already discussed. This woman has long been 
accustomed to arrest the development of a seizure by compressing 
the left ovary ; slie generally succeeds when tlie invasion of the attack 
does not take place with great rapidity. If she fail in lier effort, 
she calls on the attendants to help her in the opération. 

Let us examine a little more closely thèse incidents of convulsive 
epidemicSj as we find them narrated in history : they supply material 
for a rétrospective study which is not devoid of interest. 

The learned Hecker, writing of those who were affected with St. 
John's Dance^i remarks that they frequently complained of great 
epigastric pain^ and requested to hâve their abdomen compressed 
by bandages. 

But, in référence to this subject, we find the most interesting 
documents in connection with the épidémie of St. Médard, as it is 
called. You are aware how this took place when the religious 
exaltation of the Jansenists, persecuted on account of the Bull Uni- 
genitus, was at its climax. The épidémie, which begau at the tomb 
of Deacon Paris, whodied in 1727, presented two distinct periods. 

The first was chiefly remarkable, at least from our point of view, 
on account of the cure of a certain number of sick persons, amongst 
whom were several suffering from well-attested permanent hysterical 
contracture.^ In the second period, predominated convulsions of a 
more or less singular character, but which, in short, differ in nothing 
essential from those which characterise hysteria when it assumes an 
épidémie form. Now, itwas atthis period that the ])ractice ofgiving 
the secours (as it was called) made its appearance in the épidémie 
of St. Médard. 

Of what did this succour consist ? In most cases methods were 
employed to cause firm compression of the abdomen, or else vio- 
lent blows were given it with some instrument. Thus there were : 
1°, the succour administered by means of a heavy andiron, with which 
the abdomen was repeatedly struck; 2°, the succour given by means 
of a wooden beetle or large pestle, which difTers little from the 
former ; 3°, in this case, a man clasped his two fists togcther and 
thrust them, with ail his might, against the abdomen of the " con- 

^ Hecker, " Danse de St. Jean," Aix-la-Cbapellc, 1374, " Epidémie de St. 
Witt," à Strasbourg, 1437. 

- Carré de Montgeron, loc. cit. 

3 Bourneville and Voulet, " De la contracture hystérique iiermancnte," pp 
7-17, Paris, 1872. 



HTSTEEIOAL EPIDEMICS. 275 

vulsionnaire, and, tlie better to succeed, he called other men to assist 
liim ; 4°, tliree, four, or even five persons got upon th.e body of 
the sufferer — a " convulsionnaire," called bj her co-religionists, 
Sister Margot, had a particular prédilection for this species of suc- 
cour ; 5°j finally, there is a case wliere long bands were disposed 
so that they miglit be drawn tight to left and right, and tlius com- 
press tlie abdomen. Thèse modes of succour, wliichever kind was 
adopted, were always, it appears, followed by great relief. 

Hecquet, a physician of the period, declined to see in thèse con- 
vulsions, which others attributed to divine influence, anything but 
a natural phenomenon, — and so far he was perfectly right. But I 
camiot sliare his opinion when, in his work entitled, ' Du Naturalisme 
des Convulsions,' he maintains that the modes of succour were noth- 
ing else than practices suggested by lubricity. For my own part, I do 
not well see what lubricity could hâve to do with blows of pestles and 
andirons administered with extrême violence, although I am far from 
forgetting what a depraved taste may give birth to, in this affection. 
I believe it is very much simpler and very much more legitimate to 
admit that the succour — apart from the amplifications suggested by 
a love of notoriety — corresponded to an empirical practice, the resuit 
of which was to give great relief in cases of hysterical seizure. 

X. 

You hâve assuredly remarkcd, gentlemen, the analogies which exist 
bctween this arrest of hysterical or hystero-epileptical convulsions, 
determined by abdominal compression, and the arrest of convulsions 
which is sometimes effected by a ligature of the lïmh from which 
the phenomena of the aura, in such cases, take their rise. This, 
perhaps, is the place to remind you that a sudden flexure of the 
foot causes, as M. Brown-Séquard lias shown, the immédiate cessa- 
tion of the convulsive tremulation of spinal ejrilejisj/, observable in 
certain cases of myelitis. You are not unaware, that, in expérimental 
imtliology, thèse clinical facts find, to some cxtent, their explanation. 
I caunot enter into détails at présent, let it suffice to remind you that 
numerous experiments on animais bear testimony to the fact that sus- 
pension of reflex excitability of the spinal cord may be caused by irri- 
tation of the peripheral nerves. Thus, the experiment of Herzen shows 
us that, in the case of a decapitated frog (which was consequently 
placed in an excellent condition to augment to the utmost the reflex 
excitability of the spinal cord), if the lower portion of the cord be 



276 CONCLUSION. 

irritated it will be impossible, so long as tliis excitation subsists, to 
call into action tlie excitability of tlie superior extremities. And, 
on the other hand, if you tie a ligature tightly round the upper 
extremities of a frog, similarly decapitated, so long as this ligature 
remains, the excitation of the inferior extremities will not be foUowed 
by reflex movements. Tins, at least, is what is demonstrated by 
Lewisson's experiment. 

However, although thèse facts are more easily analysed they are 
not, in the actual state of science, more easily explained than the 
corresponding pheuomena observable in man. 

XI. 

Time presses, and I cannot dwell any longer upon this subject.- 
I should, however, hâve liked to show you the importance, from a. 
practical point of view, of suppressing severe fits of hysteria, or, at 
least, of moderating their intensity. But this aspect of the question 
may be more appropriately illustrated when I shall hâve described, 
in another conférence, the conséquences which follow reiterated fits, — 
otherwise, termed the Jiystero-e^ileptlcal acme?- I will confine myself, 
at présent, to formulating as follows, one of the conclusions deducible 
from the présent study : 

Energetic compression of the painfal ovari/ Jiasno direct influence 
over viost of tlie permanent srjmptoms of hysteria, such as contrac- 
ture, paralijsis, hemianœsthesia, S)'c. ; but it has a frecpientli^ 
décisive effect iq^on the convutsive attaclc, the intensity qfîchich it 
can diminish, and even the cessation of tvhich it may sometimes 
détermine. 

XII. 

I hâve, in conclusion, gentlemen, to introduce to your observation 
the patients whom I hâve h ad chiefly in view in the preceding 
description, and to point ont the most salient peculiarities which 
they présent. 

Case I, — Marc — , set. 23, suffering from hystero-epilepsy since 
the âge of sixteen. It is not certain to what cause the origin of the 

• In Trench, état- de-mal hi/stéro-épileptique. Prencli pathologists euiploy 
the terin état {status, àKfitj) to designate that period of a disease when the 
symptonis, having attained their utmost intensity, may remain for some time 
stationarj, as it were. (S.) 



CLINICAL CASES. 277 

flisorder should be attribiitecl. However that may be, she présents 
the following phenomeua of local hysteria : liemianasthesia, ovaria, 
and paresis, on the left side. She is likewise subject to fréquent 
vomiting, and bas liad achromatopsia of the left eye. 

The attacks are preceded by a characteristic aura ; the premoni- 
tory phenomena start from the left ovary, and the' cephalic symptoms 
are very marked. With respect to the seizures, they are com- 
posed of three periods : a, tetaniform, epileptiform convulsions, 
foaming at the mouth; — h, (period of contortions) great movements 
of the body and lower extremities ; during tins stage, the patient gives 
utterance to strange words, and seems a prey to moody delirium ; — 
c, tears and laughter announcing the end of the attack. In her case, 
a prompt and absolute cessation of ail the phenomena is determined 
■ by compression of the left ovary. 

Case II. — Cot — , œt. 21, hysteria began at the âge of fifteen. 
The ill-treatment she had sufîered from her father, who was addicted 
to alcoholic excesses, and her subséquent career as a prostitute, hâve 
■doubtless exerted a certain etiological influence. The local hysteria 
is still more marked in this case, than in the former one. We hâve 
to note on the right side hemianœdhesïa, ovarïanjicàn, w^d j^ermanent 
contracture with tremulation of the lower extremity. 

The attack is heralded by a distinct aura,proceeding from the right 
ovary, and terminating in very évident cephalic symptoms. The 
convulsions, which are chiefly tonic, are complicated by epilepti- 
form phenomena ; C — bites her tongue, foams at the mouth, &c. 
The period of contortions follows, and is very intense. The attack 
frequently terminâtes by contortions of the pelvis, with laryngeal 
constriction, tears, and an abundant flow of urine. In her case, 
compression of the ovary modifies the intensity of the fit, without, 
however, arresting it. In the first months of the year, this patient 
was stricken with the Iiystero-epileptical acme, to which we will 
return in another lecture.^ 

Case III. — Legr — Geneviève was born at Loudun. The coïn- 
cidence is curions — for that, you know, was the scène of the sad 
drama of which Urbain Grandier was the victim. Geneviève is 38 
years of âge; her hysteria dates from the period of puberty. Among 
the permanent symptoms of local hysteria, we observe well-marked 

^ This case is detailed in full iu the treatise by Bourneville and Voulet, ' De 
la contracture permanente.' Obs. viii, p. 41. 



278 CLINICAL CASES. 

left hemianœsthesîa, left ovarian j)ain, with easily discerned tuméfac- 
tion. Her mindj finally, is in a strange state. 

The mcru is very distinct, and the cardiac palpitations and cephalic 
phenomena constitute the prédominant symptoms. Each seizure 
is divisible into three stages : i°, epileptiform convulsions, foaming, 
and stertor; 2°, then contortions of the limbs and entire body; 3°, 
the period of delirium, during which, at the close of complète attacks, 
she relates ail the incidents of her life. 

Sometimes the patient, inthis latter phase, has hallucinations; she 
sees ravens and serpents ; moreover, she commences a kind of 
dance, and then she exhibits, as it were, in an embryonic state and 
sporadic form, a spécimen of those dances of the middle-ages, de- 
scribed under the name oî saltatory épidémies (or the dancing mania) . 
In connection with this, I would hâve you note that certain cases of 
hysteria — forming, insomesort,varieties within the species — présent 
in a rudimentary state the différent convulsive forms which are ex- 
hibited in a highly developed state in the time of épidémies. This, 
indeed, is a point which Yalentiner has thoroughly discussed in 
his interesting work on hysteria.i 

In Geneviève's case, compression of the ovary détermines what 
we might call a sudden arrest of the attack. She has a clear con- 
ception of its influence, for she herself tries to compress the région 
which gives birth to the aura, and when she cannot succeed, she, as 
we hâve already mentioned, calls for help from the attendants. 

Case IV. — Ler — , set. 48, is a patient well known to ail the 
physicians who, during the last twenty years, hâve frequented this 
hospital, in the discharge of various duties. In other words, hers is 
a cas célèbre in the annals of hystero-epilepsy. You will find the 
early portion of her history narrated in the thesis of M. Dunant (of 
Geneva). Ler — ceased to menstruate four years ago_, notwithstand- 
ing which, the nervous accidents persist. We called on you just 
now to observe the présence of a rudimentary form of Tarantisr/i 
in Geneviève^s case ; Ler — is a Demoniac, one " possessed by a 
devil,^' — or, again, she présents the image, not much fainter than 
the reality, of one of those women who were called " Jerkers " in 
the Methodist Camp Meetings, and who assumed the most horrify- 
ing attitudes in their paroxysms. (See Figs. 1 9, 20 and 21.) 

' Valentiner (Th.), " Die Hystérie uud ihre Heilung," v. q. extract ia 
'Mouvement Médical,' June, 1872. 



CLTNICAL CASES. 



379 



The probable cause of thèse nervous accidents in the case of Ler — 
deserves mention. Slie had, as she says, a séries of frights : i°, at 
the âge of eleven, she was terrified by a mad dog ; 2°, at the âge of 
sixteen, she was struck witli horror at sight of the corpse of a 
murdered woman ; 3°, at the same age^ she was again terrified by 
robbers who, as she was passing through a wood, rushed out to 
despoil her of the money she carried. 




FiG. 19. — Attitude of Ler — during the attack; period of contortion. (Fac- 
simile of a sketch from nature.) 

The components of local hysteria, in her case, are formed by 
hemianœsthesia, ovaria, paresis, and momentary contractures of 
the upper and lower extremities on the right side. Sometimes the 



280 



CLINICAL CASES. 



phenomena invade tlie left side, and tlien, in accordance with our 
description, we find double o varia, witli double ansesthesia, &c. 




FlG. 20. — Attitude of Ler — during tbe attack ; period of coutortion. (Fac- 
simile of a sketch from nature.) 

The attacks, which are heralded by a well-marked ovarian aura, 
are characterised in the first stage, by epileptiform and tetaniforin 
convulsions; after tbis corne great gesticulations of a voluntary 
character, in whicli tbe patient, assuming the most frightful postures, 
reminds one of the attitudes which history assigns to the deraoniacs ; 
(period of contortions, Figs. 19, 30 and 21). 

At this stage of the attack, she is a prey to delirium, and raves 
cvidently of the events which seem to hâve determined lier first 



CLINICAL CASES. 



281 



seizures. She hurls furious invectives against imaginary individuals, 
crying out, " villaius ! robbers ! brigands ! fire ! lire ! 0, tbe dogs ! 




ElG. 21. — Hystero-epileptic attack ; period of contortions. (Drawn by M. 
Pùcher from a sketch made by M. Charcot.) 

l'mbitten ! " — Hemiuiscences, doubtless, of the émotions experienced 
in her youth. 

"Wlien the convulsive portion of the attack is ended, there super- 
vene, as a gênerai rule : i°, hallucination of vision ; the patient 
beholds horrible animais, skeletons, and spectres; 2°, paralysis of 
the bladder ; 3°^ paralysis of the pharynx ; 4°, and lastly, a more or 
less marked permanent contracture of the tongue. 

Thèse latter phenomena occasionally render it necessary to hâve re- 
course, for several days, to the use of the cathéter, and to the 
employment of the stomach pump for alimentary purposes. 

Compression of the ovary, in this case of Ler— , is almost void of 
effect upon the convulsions.^ 

' We published the detailed account of this patient's case in the 'Progrès 
Médical; (Nos. 18-33, 1875). 



283 CLINIOAL CASES. 

Case V. — You are already acquainted with this patient, named 
Etch — ; it is she who furnislied us with materials for oui lecture 
on liysterïcal ischuria.^ We note, also, in this case, the présence 
of Jiemianœsthesïa, ach'omatopsla, contracture, and avaria on the 
left side. The attacks are principally tetaniform and tonic. We 
hâve not, hitherto, had the opportunity of testing, in her case, the 
influence of ovarian compression upon the convulsions. 

^ FicI^ ante, Lecture ix. 



LECTURE XII. 

HYSTERICAL CONTRACTURE. 

SuMMARY. — Forms of hysterical contracture. Description of the 
hémiplégie forni ; analogies and différences hetioeen hysterical 
contracture and that resnlting from a circumscribed lésion of the 
hrain. Example of the paraplegicform of hysterical contracture. 
Prognosls. — Sudden recovery in some cases. Scientific expia- 
nation of certain reputedly miraculous events. Incurahility of 
contracture in a certain number of hysterical patients. Examples. 
Ânatondcal lésions. Sclerosis of the latéral columns. Farieties 
of contracture. Hysterical cluh-foot. 

Gentlemen, — lu his standard treatise on hysteria, M. Briquet, 
though lie does not give to the liistory of permanent contracture, 
which may affect one or several members in hysterical cases, ail the 
considération that in my judgment it deserves, yet traces witha sure 
hand the most salient features of this symptom. This, he writes, is 
a rare complication. He had, in fact, only met with it six times at 
the period when he published his work. In one case, the contrac- 
ture occupied one limb only ; in two others, it appeared under a 
hémiplégie form ; and in the last three cases, it assumed the para- 
plégie form. It is perfectly true that hysterical contracture can 
présent thèse several aspects. You will, besides, verify the fact for 
yourselves, as I am fortunate enougli to be able to place under 
your observation two patients, one of whom présents the hémiplégie 
form and the other the paraplégie form of hysterical contracture. 
We are thus enabled to make you touch with the finger, as it were, 
the most interesting peculiarities connected with this singular mani- 
festation of hysteria. 



284 



HYSTEEIOAL CONTRACïUrxE. 



Etch — , now aged 40 years, lias been affectée! for twenty months 
witli left hemiplegia. You perceive tlie superlor extremïty of this 
sicleis in semi-flexion (fig. 22); it is theseatof considérable rigidity, 
a fact attested by tlie difficulty experienced in trying to increase the 
flexion, and tlie impossibility of obtaining complète extension.^ 




?1G. 22. — Contracture of Icft uppcr extrcmity. 

The left lower extremity is in extension; its several parts are, 
co to speak, in a forced posture. Tlius tlie tliigh is strongly 
extendcd on the pelvis, tlie leg upon tlie tliigli. The foot pré- 
sents a most marked example of talipes equino-varns. In addition 

1 At the i)reseut moment (July, ICS73) tlie contracture of tlic left extremi- 
tics is observable, with ail the charactcristics describcd in tlie lecture, whicli 
was dclivcrcd in June, 1870. [Etch — bassinée recovcred, sce in/rà, pp. 290-1- 
S.] 



HEMIPLEGIC FOEM. 285 

to this, tlie adductor muscles of tlie tliigh are, also, spasmodically 
contractured. In short, ail the joints are alike rigid, and tlie whole 
limb forms as it were an inflexible bar, for, by grasping the foot, you 
can raise, in one pièce, the inferior portion of the patient's body. 
I lay particular stress upon this attitude of the lower extremity, 
because it is very rare in hemiplegia arising from circumscribed 
cérébral lésion {en foyer), and is, on the contrary, asit were the rule 
in hysterical contracture. In the latter case, permanent flexion of 
the thigh and leg is, to judge from my own expérience, a really 
exceptional fact. 

We hâve hère di permanent contracture in the rigorous sensé of the 
Word ; I hâve assured myself that it is nowise modified during the pro- 
foundest sleep ; in the daytime, there are no alternations of increase 
or remission. The slumber alone, which chloroform procures, causes 
it to disappear if the intoxication produced be considérable. 

Although the hémiplégie contracture by which our patient is 
affected is, I repeat, of nearly two years standing, you perceive that 
the nutrition of the muscles has not sensibly sufl'ered. I should 
also add that the electrical contractility has remained nearly normal. 

I would point out to you, in passing, that, by forcibly setting back 
the pointof the foot, you détermine in the contractured lower extremity 
a trépidation which sometimes persists long, even when the foot is 
let go, and allowed to résume its former attitude. You are aware that 
this same trépidation is very commonly met with in paralysis with 
contracture, arising from an orgauic spinal lésion, as, for instance, 
when the latéral columns are afîected with sclerosis; but I hâve 
likewise seen it, in a number of cases, in which hysterical contracture 
ended suddenly in the patient's recovery. Hence, you will observe 
that this phenomenon is not one of absolute worth, so far as an 
anatomical diagnosis is concerned.i 

' In 1868, in the course of my lectures at La Salpê trière, I called attention 
to the peculiar trembling which, in certain patients afFected by paralysis, or 
even by paresis, of the lower extremities, was produced in the foot when 
it was caught by the point and suddenly turned back {v. A. Dubois,. 
" Etude sur quelques points de l'ataxie locomotrice progressive," ' Thèse de 
Paris,' 1868). 

The trépidation, thus provoked, generally stops as soou as the foot is no 
onger kept iu dorsal flexion ; sometimes, however, it persists for a little time 
after. Limited to the foot in many cases, it extends often to the entire 
limb, and sometimes even to the lower extremity of the opposite side. In 
cases where the trembling in question can be provoked by the method de- 
scribed, it frequently also shows itself, either spontaneously (at least appareutly 



286 CHARACTERS OF HYSTEEICAL CONTRACTURE. 

Leaving out of tlie question the différence we hâve mention ed re- 
specting the attitude of the lower extremity, ail the othcr peculiarities 
we hâve described might^ strictiy speaking, apply to a case of organic 
hemiplegia, resulting from a deepseated lésion of the encephalon, 
as hsemorrhage or ramollissement, for instance. 

Another feature of resemblance is the following : hemiplegia 
showed itself suddenly in Etch — duriug a seizure. After this 
attack; the patient remained for several days without consciousness. 

so) or under the influence of tlie movemeuts made by the patient to raise 
himself in bed, to rise from it and stand, or again whilst walking. 

Trépidation of the foot, whether provoked or spontaneous, sliows itself in 
varions circumstances when the latéral fascielcs of the spinal cord hâve beeome, 
throughout a certain extent, the seat of a slow connective prolifération. Thèse 
conditions are, it is plain, the same as those in which, at a later pcriod thau the 
trembling, the production of permanent contracture takes place. Thus spon- 
taneous or provoked tremulation, whether limited to the foot or gencralised, is 
observed in symmetrical sclerosis of the latéral columns, m disseminated 
sclerosis, whenever the spinal foci occupy the latéral columns to the extent of 
some inches in length. They are seen when sclerosis descende?is has been 
established consecutively on compression of the cord, caused by a tumour ; in 
acute or subacute transversal myelitis ; or, again, in latéral sclerosis, consécutive 
on certain cérébral lésions such as, for instance, circumscribed ramollissement, 
or hsemorrhage of the opto-striate bodies, involving the capsula interna. The 
tremulation in question is, therefore, not the appanage of auy one disease in 
particular, it is eonnected with affections of very différent origin, but in which 
latéral sclerosis is a common feature. However, its présence in cases of 
hysterical contracture, terminating abruptly in recovery, shows that it cannot 
always be attributed to a perceptible material lésion of the latéral columns 
(Dubois, loc. cit., Charcot et Joffroy, 'Archives de Physiologie,' 1869, pp. 632 
€t seq. ; Charcot, ' Leçons sur les Maladies du Système Nerveux,' ire Edition, 
pp. 218, 307, 319). 

Quite recently Herr Westphal and Herr Erb hâve each devoted to the study 
of this symptom a treatise, accompanied with ingénions physiological views. 
According to thèse authors, provoked trépidation of the foot (which is desig- 
nated by Herr Westphal under the name Fiiszphiinomenon) would be a reflex 
phenomenon, having its starting point in the tendons (W. Erb, " Sehnenrcflexe 
bei Gesiindcn und bei Kiickenmarkskranken," ' Archiv fiir Psychiatrie,' iv 
Bund, 3 heft, p. 792, 1875; C. Westphal, " Ueber einige Bewegungs- 
Erscheimungen an gelahmteu Gliedcrn," Idem, p. S83 ; W. Erb, " Ueber 
cinen wenigbekannten Spinalen Symptomencomplex," in ' Bcrlincr Klin. 
Wochensehrift,' 1875, No. 26). 

In some casses of paralysis of the upper extremities, when, for example, we 
bave hemiplegia consécutive on lésion of the internai capsule, and when perman- 
ent contracture is not too markcd, we can succced, by suddenly cxtendiug the 
fingcrs, in producing a spasmodic trembling of the hand, similar in cvcry 
respect to provoked trépidation of the foot. (J. M. C.) 



CHAEACTEES OF HYSTEEIOAL CONTRACTURE. 287 

Having indicated the analogies, I must point out the différences. 
They are numerous and emphatic, and in point of fact, nothing is 
more simple than to assign hysterical contracture to its proper cause, 
by taking note of cliaracters whicli are almost always présent. 

3°. E,emarkj in the first place, gentlemen, the absence of facial 
paralysis and of déviation of the tongue, when that organ is pro- 
truded. You know that thèse phenomena always, on the contrary, 
exist to sorae extent in hemiplegia resulting from circumscribed 
cérébral lésion.^ 

2°. Observe also the existence of an analgesia and of an 
ansesthesia, which may be termed absolute, extending over the 
entire paralysed half of the body, and consequently occupying the 
face, trunk, &c. This altération of sensibility involves not only the 
skin, but also the muscles, and perhaps the bones ; it stops exactly 
at the médian line. 

This kind of generalised ansesthesia, occupying a complète half of 
the body, — head, trunk, and members — this quasi-geometrical limita- 
tion of the ansesthetic portion by a vertical plane dividing the body 
into two equal parts, are, as it were, the peculiar property of hysteria.^ 
However it happens, this symptom is very rarely observed in hemi- 
plegia of cérébral origin, and in case of spinal hemiplegia, that is, of 
hemiplegia resulting from a unilatéral lésion of the spinal cord, the 
ansesthesia, as M. Brown-Séquard has shown, would occupy the side 
opposed to that affected by motor paralysis. 

3°. We hâve many other distinctive characters to point out. 
The patient is intelligent, and we hâve no reason to suspect her 
sincerity. She can, therefore, give us authentic information with 
respect to the mode of évolution of her affection. Tlie following is 
a succinct account of her history. 

There were not, it appears, any hysterical antécédents in her case. 
The disease set in, when she was 34 years of âge, after a violent 
moral shock, with a seizure accompanied by loss of consciousness. 
This attack, according to ail probability, assumed the epileptic form 
of hysteria. Etch — , in fact, fell during the fit into the fire, and she 
bears on her face the traces of the burn which she then received. 

' According to Herr Hasse (' Handbuch der Path., &c.,' 2 Auflaç, Erlangen, 
1869) Herr Altliaus was the first to point out the absence of facial paralysis, and 
of lingual and buccal déviation in hysterical hemiplegia. This is not the case ; the 
character in question had been, previously, prominently set forth in K,. B. Todd's 
"Lectures on the Nervous System." 

■' V. antè, Lecture X on " Hemianœsthesia." 



288 CHAEAOTEES OF HYSTERICAL CONTEACTUEE. 

Eenewed attacks, at times plainly hysterical, at times exhibiting some 
of tlie aspects of epilepsy, supervened^ repeatedly, during tlie follow- 
ingyearsj but, at the âge of 40, appeared the permanent symptoms 
of hysteria wliicli we hâve at présent to study. We should, tbere- 
fore, mention in what concurrence of circum stances tbey were de- 
veloped, for we sliall find tliere some characteristic features. 

a. Menstruation which, until then, had been regular, became 
disordered; the patient, from time to time, had vomitings of 
blood ; 1 there was considérable tympanitis^ with acute pain on 
pressure in the left ovarian région. This pain was of a spécial 
character, being accompanied by peculiar sensations which radiated 
towards the epigastrium, and which were noticed by the patient as 
heralding most of her seizures. Thèse symptoms, including the 
tympanitis, and rétention of urine, are still in existence. 

b. Almost simultaneously with the occurrence of thèse phenomenon, 
Etch — became subject to persistent rétention of urine, which néces- 
sitâtes the constant employment of the cathéter. 

c. Matters were still in this state, when, in October, 1868, there 
supervened a very severe attack, accompanied by convulsions and 
followed by an apoplectiform condition with stertorous breathing ; 
then hemijilegia suddenly made its appearance. 

Now, gentlemen, tins considérable tympanitis, thèse pains in the 
ovarian région, this rétention of urine, constitute a group of symptoms, 
the importance of which is nearly décisive in diagnosis. Nothing 
similar is to be seen in the premonitory symptoms of hemiplegia 
arising from cérébral lésions, whilst it is very common, on the contrary, 
to find thèse symptoms preceding the appearance of the permanent 
phenomena of hysteria, whether hemiplegia or paraplegia, This is 
a point which M. Briquet has not failed to bring out ; it is likewise 
properly noticed, so far at least as hysterical paraplegia is concerned, 
by Dr. Laycock, in the following terms : " In hysteria, more or less 
severe paralysis of the lower extremities is always accompanied," 
he might hâve added, *'and preceded," " by a corresponding 
degree of perturbation in the functions of the pelvic viscera; this 
perturbation is manifested by constipation, tympanitis, vesical 
paralysis, increase or diminution of the urinary sécrétion, ovarian 
or utérine irritation, &c."^ 

^ This is a fréquent accident in hysterical patients, when there is a notable 
dérangement of the catamenia. 

'Treatise on the Nervous Diseases of Women,' London, 1840, p. 240, 



HEMIPLEGIC AXD PARAPLEGIC FOEMS. 289 

d. AATien Etch — was adinitted a year ago, (Juiie, 1869), to La 
Salpêtrière, tlie hemiplegia had been seven or eight montlis in exis- 
tence. Independently of the cliaracteristic peculiarities, already men- 
tioned, the state of the paralysed members could be, itself, quoted 
in faveur of the hysterical origin of the paralysis. Thus, whilst 
the upper extremity was in a state of complète and absolute flaccidity, 
the lower extremity presented very marked rigidity of the knee. 
This woukl be a considérable anomaly in a case of liemiplegia, con- 
sécutive on cérébral lésion, for, in such a case, the slowly ensuing 
rigidity prefers to manifest itself in the upper extremity. 

c. The contracture which at présent occupies the upper extremity, 
only dates from a few months back, and it was developed suddenly, 
and without transition, after a seiznre. It is not in this way, as you 
know, that w^e find the tardy contracture supervening, which results 
from hsemorrhage or ramollissement of the brain. In the latter case, 
contracture always sets in slowly and in a progressive manner. 

Thus, gentlemen, by taking note of ail the circumstances which 
hâve just been enumerated, uothing is more easy than to ascertain 
the real cause of the disease, in the case of our patient Etch — . 
In the following observation, which relates to a case of hysterical 
paraplegia,! the same facilities for making a differential diagnosis 
may be found. 

II. 

Alb — , aged 21 years, a foundling, has been affected for about 
two years with permanent contracture of the inferior extremities, 
which are, as you may observe, in extension and quite rigid. 
As in the case of Etch — , muscular contractility is not dimi- 
nished. The members are emaciated, but this emaciatiou affects 
them generally, and is due to the fact that the patient is subject to 
almost uncontrollable vomitings, which hinder her from taking sufii- 
cient nutriment. We hâve likewise to note an almost complète 
analgesia of the paralysed members. 

Now, the following are the thoroughly décisive symptoms which 
allow us to establish the diagnosis. 

a. Alb — has been subject to hysterical fits since she was sixteen 
years of âge ; h, she has been for four years affected with rétention 

^ This case was already referred to in Lecture XI. A detailed account of 
the symptoms may be found in the memoir, ' Comte-rendu des observations 
recueillies à la Salpêtrière, concernant l'épilepsie et l'hystéro-épilepsie.' (B.) 

19 



290 HYSTERICAL CONTRACTURE. PROGNOSIS. 

of urine, whicli generally requires the cmployment of tlie cathéter ; c, 
she présents enormous tympanitic distension of the abdomen ; d, the 
ovarian régions are painful on pressure, and if the exploration be 
pressed, an hysterical seizure is soon provoked ; e, contracture of the 
inferior estremities supervened suddenly, without transition, — and 
this is a symptom which we hâve already had occasion to emphasise 
in the preceding case. Now, such symptoms are not to be met with 
during the progress of sclerosis of the latéral columns. 

III. 

Thus, gentlemen, nothing, I repeat, is simpler than the clinical 
interprétation of thèse two cases, so far as the diagnosis is con- 
cerned. But hère is a point where, in thèse and in analogous cases, 
serions difficulties may arise. 

What will become of thèse patients? In their case, paralysis 
with contracture has persisted, without amendment for four years. 
Will this contracture some day be resolved, or will it, on the con- 
trary, persist indefinitely, and so become an incurable infîrmity? 
Thèse are questions which we must ask, without, however, pledging 
ourselves to give categorical answers. 

A. It is possible that, in spite, of its long duration, this contrac- 
ture may, without leaving any trace of its existence, disappear — 
perhaps to-morrow, or in a few days, or a year hence. We can 
f orteil nothing concerning it. In any case, if recovery talces place, it 
may he sudden^ From one day to the next, resumption of the 

' Dr. Laycoek remarks tliat a woman may hâve been bed-ridden for several 
months, and quite uuable to use lier lower extremities, the physieian may hâve 
given up ail hope of being of any assistance to her, when suddenly, under the 
influence of some potcnt moral cause she will be seen to rise from lier bed 
" no longer the victim of nerves, but the vanquisher," as Thomas Carlyle says, 
and walk about as well as if she had never been stricken with paraplegia. 
This is one of the terminations of hysterical paraplegia which the physieian 
should never losc sight of, and which well shows what risk he runs in pro- 
nouncing a case of this kind to be incurable. T. Laycoek, ' A ïreatisc on the 
Nervous Diseases of Women,' London, 1840, p. 289 (Note to first French 
Edition). 

This anticipation was fulfillcd during the présent year, as regards the first 
mentioncd. of the two patients to whom allusion was made in this passage, 
italiciscd in the first édition, 'i'he state of Etch — on the 2ist of May, 
may be thus summed up : rétention of urine, with periodic ischuria, during 
nine years; contracture of the right lower extremity; contracture of the 
mcmbers on the lei't sidc, of six years' standing; contracture of the jaws. 



STJDDEN EECOVERY. 291 

normal state may occur ; and if it sliould liappen, that at tliis period, 
tlie liysterical diathesis is exliausted, the patients may once more 
take tlieir place in every-day life. 

In connection with tliis, gentlemen, I cannot resist pausing a 
moment in présence of thèse rapid and often unlioped-for recoveries 
from a disease whicli, during such a length of time, had made itself 
remarkable on account of its tenacity and its résistance to ail thera- 
peutic agents. A sudden strong émotion, a concurrence of events 
taking powerful hold of the imagination, the reappearance of long- 
suppressed catamenia, &c.' — occurrences such as thèse are frequently 
the occasions of those prompt recoveries. 

I hâve seen in this hospital, three cases of the kind which I 
request your permission to briefly summarise. 

1°. In the first case, there was contracture of a lower extremity 
(fîg, 23), of at least four years' standing. On account of the mis- 
conduct of this patient, I was obliged to give her a stern admonition 
and déclare that I should turn lier out of the hospital. Next 
day, the contracture had entirely disappeared. This fact is the 
more important, because convulsive hysteria existed only as a bye- 
gone fact in her memory. Por two or three years past, the con- 
tracture had been the only manifestation of the great neurosis. 

2°. The second case, likewise, concerns a woman affected by 

necessitating the use of the stomach-pump, of one year's standing ; aphonia, 
lasting during ten months. On tiie 23ud May, at a quarter past seven 
o'clock in the evening, she was seized with a fit, marked chiefly by great 
oppression ; contracture of the neck-muscles, on the left, which twisted the chin 
behind the left shoulder. The patient does not lose consciousness, she believes 
she is going to die; she shrieks, — the contracture of the jaws vanishes. 
She tosses about, the attendants eudeavour to restrain her ; with her right 
arm, which has become free, she repels those who hold her. She wants to go 
to the window for air; and, being opposed, her passion increases, and under 
this influence it was observed that contracture of the righfc leg disappeared, and 
that this was followed by disappearance of that of the left Icg, and next by 
that of the left arm, in succession. Etch — is allowed to rise ; she walks 
about ; in eighteen liours recovery tous complète, or nearly so. Dating i'rom 
the next day, the urinary sécrétion became normal again (PL x). The arnblyo- 
pia and ansesthesia did not completely disappear until a few days had elapsed, 
and the patient has only retaiued some cracking Sound in her joints, principally 
in those of the left leg, as vestiges of her permanent contracture. Li conclu- 
sion, the only traces of former accidents to-day, are some slighfc cracking sounds 
in thejoints of the limbs previously affected by contracture (B.) (Note to the 
Second Freuch Edition.) 



292 



SUDDEN EECOVEEY. 



permanent contracture of one member only. The liysterical crises, 
proper, liad long disappeared. This woman was charged with tlieftf 




FiG. 23. — Hysterical contracture of tiie right lower extremity. 

the contracture which had lasted for two years, vanished suddenly on 
account of the moral shock caused by this accusation. 

3°. In the third case, the contracture had assumed the hémi- 
plégie form ; it affected the right side, and was particularly évident 
in the upper extremity. Recovery took place almost suddenly, 
eighteen months after invasion, on account of a sudden disap- 
pointment. At that time there was no ansesthesia, and the patient, 
whilst confessing to having experienccd strange nervous dérange- 
ments, denied the existence of any real hysterical seizures in the past.. 

It is necessary to recognise, gentlemen, the possibility of those 
recoveries which, even at the présent day, hâve been cried up as 



INCUEABLE CONTRACTURE. 293 

miraculous by some, but of wliicli only charlatans take the crédit to 
themselves, in self-glorification. In former times, similar cases 
were frequently cited, when it was sought to prove before sceptics 
tlie influence of the supernatural in therapeutics. Prora. this point 
of view, you will read with interest an article published in tlie Revue 
de Philosophie Positive (ler Avril, 1869), by the vénérable M. 
Littré.i I allude to an essay entitled, Vn fragment de Médecine rétro- 
spective (Miracles de Saint Louis), in which is found an account 
of several cases of paralysis cured after pilgrimages to St. Denis, to 
the tomb where the mortal remains of King Louis IX had recently 
been deposited. Three of thèse cases are especially interesting to us 
on account of the exactness of their détails. They relate to women, 
still young, who were suddenly seized with contracture of one of the 
lower extremities, or of botli members on the same side of the body, 
which likewise presented considérable ansesthesia. In thèse cases, 
recovery took place suddenly, in the midst of circumstances well 
adapted to strike the imagination. You see, gentlemen, that things 
hâve little changed since the close of the thirteenth century.^ 

But if the recovery of thèse patients is possible, and even probable, 
it does not necessarily take place, and it may be that the contrac- 
ture will persist, as an incurable infirmity. This is an assertion, 
which it will not be difficult for me to justify. But, allow me to 
point out to you that, in most authors, you will only find vague, un- 
certain, and far from satisfactory assertions in référence to this 
subject. 

a. I introduce to you a patient, now aged ^^ years, who, eighteen 
years ago, was seized, after an hysterical attack, with paraplegia ac- 
companied by contracture, the principal characters of which you can 
still recognise. At the beginning, the contracture from time to time 
gave évidence of temporary amendment. But, for over sixteen years, 
it has never undergone the least modification. In this case, we hâve 
a real rigidity of the muscles, with prédominance of the action of 
the extensors and adductors. Even after sixteen years of immobility 
of the lower extremities, the ligamentous parts are not afl^ected, at 
least not in the knees, as we hâve been enabled to verify by an 

^ Very little, in reality, for the professedly miraculous cures, concerning 
Tvhich so mucli noise lias been macle in thèse later days, do not diifer in any 
perceptible character frorn the miracles of St. Louis. The reader may cou- 
vince himself of this by a perusa! of the work recently published by M. Diday, 
;<entitled, 'Examen Médical des Miracles,' &c., Paris, 1873 (Bourueville). 



294 



SCLEROSIS OP LATERAL COLUMNS. 



exploration made whèn tlie patient was under chloroform. The 
deformity of the feet alone, wliicli resembles that of talipes eqnino- 
varus, was net modified during this artificial sleep. The muscles 
of the legs and thighs are markedly atrophied, and faradaic con- 
tractility is diminished there. During many years, hysteria seems 
to hâve been completely exhausted in this wornan^ and it has become 
very improbable that any event could henceforth alter, in any way, the 
state of her lower extremities. (Fig. 24).! 







FiG. 24. — Hysterical contracture of botk iuferior extremities. 

h. What condition then has supervened thus to maintain the ex- 
istence of this parajîlegia with rigidity of the limbs? Evidently, 
in récent cases of hysterical contracture, tlie organic modification 
which produces permanent rigidity, whatever it may be, whatever seat 
it occupy,is veryslight, and very fugitive, since its correlated symptoms 
may disappear suddenly and without transition. It is certain that, 

' For a detailcd accouut of this case see p. 53 of the mcmoir entitled ' De 
la contracture permanente,' &c. (B.) 



SCLEEOSIS OF LATERAL COLUMNS. 295 

with tlie means of investigation whicli we possess at tlie présent day, 
tlie most minute necroscopic scrutiny would not be capable of dis- 
covering, in sucli cases^ the traces of this altération. But is it the 
same with respect to inveterate cases ? No, gentlemen, I believe I 
can assert, basing my opinion on my knowledge of an analogous 
case, that in this woman there supervened, at a certain period, a 
scierons lésion of the latéral columns, which would be discernible 
now, if an examination were possible. 

It has happened to me, in fact, once to discover, in the case of 
an hysterical woman (who was for ten years affected with contracture 
of ail four members, which had suddenly supervened), a slerous lésion 
which occupied symmetrically the latéral columns throughout nearly 
the whole length of the spinal cord. On several occasions this woman 
experienced temporary remissions of the contracture, but after a last 
seizure, it had become definitely permanent.^ 

' Société Médicale des Hôpitaux, Séance du 25 Janvier, 1865. Precisely 
as we, sometimes, find a spinal lésion, auatomically perceptible, in inveterate 
cases of hysterical contracture, so also may visual troubles be accompanied by 
lésions of tlie fuudus, which an ophthalnioscopic examination will reveal. A 
student of La Salpêtrière, M. A; Svynos, has giveu in bis inaugural thesis ('Des 
Amblyopies et des Amauroses Hystériques,' Paris, Juillet, 1873) nearly ail that 
relates to this subject. He has, in particular, described in détail the ophthalmo- 
scopic phenomena uoted on différent occasions in the case of Etch — . 

In this case, which has beeu repeatedly referred to (Lecture IX and XI), 
no lésion was discovered for a long time in the fundus of the ieft eye, 
affected by hysterical amblyopia ; but a latcr examination, made March 2oth, 
1873, by M. Galezowski, revealed the followiug altérations : 1°, the papilla is 
uniformly red over its whole extent, a pheucmeuou consécutive on capiUary 
congestion ; 2°, the borders of the papilla are effaced, blurred, on account of 
a diffuse serous exudation which extends along the vessels over the retina ; 
3°, the principal brauch of the central artery, which is distended in the lower 
part of the retiua, présents a fusiform dilatation, whilst near the papilla it 
seems to be in a state of spasmodic contraction. Accordiug to M. Galezowski : 
•' There is reason to suppose that ail thèse disorders are due to spasmodic 
contraction of the arteries in some places, and their dilatation in otliers. 
Hence the occurrence of papillary congestion in some parts, and of ansemia 
in otliers, a state of things resulting in ]3eri-papillary serous infiltration." (B.) 
See also the case recorded by M. Bonnefoy, in the 'Le Mouvement Médical,* 
1873, p. 276 (Note to the First Edition). 

In ail the patients affected by hysterical amblyopia, who were recently 
examined by M. Laudolt at La Salpêtrière, the visual field for wbite and for 
colours was found to be concentrically diminished, even in cases where visual 
acuity and central perception of colours are normal in the eye of the non- 
ansesthetic side. AU the functious of the retina of the eye, on the affected 



296 PATHOLOGICAL PHYSIOLOGY. 

It is undoubteclly legitimate to draw from thé foreging facts,^ some 
inductions relative to the patliological physiology of hystcrical con- 

side, hâve proportionately decreased. For détails relating to diminution of 
the Visual field for colours, in hysterical patients, see PI. ix, fig. 2, which 
represents the phenomena noted in the case of Marc — and the account by 
which it is accompauied. (Note to the Second French Edition.) 

' To the cases mentioned by M. Charcot, the following, noted in his wards, 
should be added, confirming as it does his teaching in every particular. 

Berf.he Chat — , aged iS years and a half, (July, 1S73), "^^^ subject from 
childhood until her twelfth year, to epistaxis, always supervening in the riffhi 
nostril ; and from the âge of twelve until she was fifteen, to cephalalgia, 
alfecting her at monthly periods nearly. At fifteen, without any known 
cause, and irrespective of any appréciable hereditary influence, she had 
suddenly a convulsive seizure, with loss of consciousness. Rare during her 
sixteenth and seventeenth years, thèse attacks were multiplied in the course 
of her eighteenth year. Some of them, which belong to the category of simple 
hysteria, recur during every two or three months ; others, partaking of the 
nature of hystero-epilepsy appear every month, with tolerable regularity. The 
occurrence of the catamenia (in January, 1873) did not modify, in any per- 
ceptible manner, the frequency and character of the convulsions. 

At the time of her admission to La Salpêtrière, (Sept., 1872), this young 
girl presented on her right side : 1°, complète hemiansesthesia ; 2°, ovarian 
hypersesthesia. 

Odober 8. — After an attack, accompanied by delirium lasting for about 
twelve hours, contracture of the right lower extremity with talipes equino- 
varus supervened ; the contracture is complicated by an almost constant 
tremulation (spinal epilepsy). From the loth to the 25th of October, the 
situation is unchanged, in spite of the occurrence of a hystero-epileptic 
fit. 

October 30. — Convulsive paroxysms, in which hysteria prédominâtes. During 
the second'] paroxysm, the persons who held the patient lest she might hurt 
herself, felt the right leg, which till then had been in extension, bccome 
suddenly fiexcd upon the thigh, and when the patient came to her sensés, the 
contracture had ceased. Ciiat — retained a certain degree of debility in the 
right inferior extremity, principally in the foot which was turned inwards. 

November. — Berthe walks without limping ; the right foot still turns 
inwards occasionally, and its point knocks, at times, against the left foot. 
Sometimes, also, the right leg is taken with a trembling which lasts i\Ye or 
six minutes, and which is foUowed by a sort of numbness that generally 
remains during the course of the day. " Then I can no longer feel my leg," 
says the patient. 

1873. — The nniscular debility has progressively diminished. To-day (July 8) 
Chat — is as strong ou one side of the body as on the oiher ; the right 
hemiansesthesia and ovarian pain hâve not changed. This case is an additional 
proof that hysterical paralysis, with contracture, may suddenly disappear 
without the assistance of any intervention. (B.) 



HYSTEEICAL CONTRACTURE. PEOGNOSIS. 297 

tracture. According to tlie considérations we hâve mentioned, ttie 
latéral columns, or at least their posterior portions — which préside 
over permanent contracture in cases of disseminated or fasciculated 
sclerosis — are indicated as being tlie seat of organic modifications, 
which are at fîrst of a temporary character, and give rise to hysterical 
contracture. In the course of time, thèse modifications, whatever they 
may be, give place to deeper material altérations, — genuine sclerosis 
is established. This may not be, perhaps, beyond the resources of 
our art, but, in any case, its existence most assuredly no longer allows 
us to hope for that sudden disappearance of contracture which forms 
one of the most striking characters of the disease, when it lias not as 
jet reached the most advanced phases of its évolution. 

Does there exist any sign which would enable us to indicate, with 
eertainty, the character of the case; to ascertain, for instance, whether 
the sclerosis has, or has not definitely taken up its abode in the 
latéral columns ? I do not believe, gentlemen, that in the actual 
state of science, a single symptom can be mentioned which offers, in 
this respect, an absolute worth in prognosis. 

Convidsive trépidation of the contractured members, whether 
purposely iuduced, or spontaneously supervening [sjnnal epilepsy), a 
certain degree of emaciation of the muscular masses, a slight diminu- 
tion in the energy of electrical contractility, ought not,judgingfrom 
my own observation, to make us altogether despair of seeing the 
contracture disappear, without leaving any trace behind. On the 
contrary, atrophy, limited to certain groups of muscles, especially if 
fibrillary contractions be added, similar to those we observe in pro- 
gressive muscular atrophy, or a very marked decrease of faradaic 
electricity, ought to make us suppose not only that the latéral 
columns are profoundly injured, but, also, that the anterior 
cornua of the grey substance hâve been invaded. I hâve not ob- 
served, up to the présent, thèse latter symptoms except in cases of 
hysterical contracture of very old standing, and which left but 
little hope of ever again seeing the aflected members résume their 
normal functions. 

I will add, in conclusion, that the existence of a spinal organic 
lésion, of more or less gravity, will be placed almost beyond doubt 
if, under the influence of sleep induced by chloroform, rigidity 
of the members only gives way slowly, or even persists to any 
marked extent. 

In my opinion, so long as thèse symptoms are not distinctly 



298 HTSTERICAL CLUB-FOOT. 

manifested, we should despair of nothing. It is besides important 
not to forget that latéral sclerosls, eveii when completely established, 
is far from being au incurable disorder, as I hope soon to prove to 
you. 

In the case of tlie patients to whom I bave called your attention, 
the contracture occupied eitber the whole of one member or of two 
members, or even more. But tbere are cases in Avbicli spasmodic 
rigidity remains limited to some portion of a member, as the foot for 
instance, when it produces a sort of liyderical diib-foot {talîpedal 
distortions, of M. Laycock). Quite recently, Dr. E. Boddaert 
communicated to the Médical Society of Ghent a most interesting 
case of this kiud,^ The contracture had occasioned the deformity, 
known as talipes varus. Similar cases hâve been collected and 
published by Dr. Little,^ by C. Bell,^ by Dr. F. C. Skey,^ and by 
some other authors. 

If it were not for certain reasons of propriety, I could, in my turn, 
gentlemen, relate in ail its détails the history of a case which resem- 
bles that published by M. Boddaert. 

Let it suiïice to inform you that a young girl, at présent twenty- 
two years of âge, very nervous, and belonging to a family in which 
nervous affections predominate, was, three years ago^ suddenly seized 
with painful contracture of the muscles of the left leg; it could be 
assigned to no cause, and she had not previously shown any charac- 
teristic symptom of hysteria. This contracture, which made the foot 
assume the attitude of most marked talipes equino-varus, gave way 
to several remissions in the course of the first year, but during nearly 
two years it h as remained stationary and seems permanent, (June, 
1870). 

Several of the muscles of the leg bave become greatly atrophied ; 
they likewise présent very marked fibrillary contractions, and respond ' 
but feebly to electrical excitation. Hence, I believe that there is little 
chance of seeing the contracture become resolved, more especially as 

* ' Annales de la Société de Médecine de Gand,' 1 859, p. 93. 

* A ' Treatise on the Nature and ïreatraent of Club Foot and Aualogous 
Distortions/ London, 1839, Case 35. 

^ ' The Nervous System of the Human Body,' 3rd Edition, 1836, Case 
177. 

^ ' llystcria, &c. : Six Lectures Dclivered to the Students of St. Bartho- 
lomew's llospital/ 1866, 3rd Edition, Loudon, 1870, p. 102. 



HYSTERIOAL CONTRACTURE. AMYOTROPHY. 299 

it shows but very imperfect amendment during sleep, induced by 
cliloroform. I will also point out a most interesting peculiarity;, 
from a cliiiical point of view : — this young giri bas experienced hys- 
terical seizures in the course of the last few montbs onlv. 



LECTURE XIII. 
HYSTERO-EPILEPSY. 

SuMMARY. — Ilystero-einlepsy. Meanïng qf tJds term. Opinions of 
authorSr Ejnleptiform hjsteria ; hysteria with mixed crises. 
Varieties qf hystero-epilejisy ; hystero-epilepsy loith distinct 
crises ; hystero-ejnlepsy with combined crises, or attaques- accès 
{seiziire-fits) . Biffereoices and analogies hetween epilepsy and 
Jiystero-ejpilepsy . Diagnostic signs siipplied hy examination of 
central tem/peratnre in hystero-epilej)tic acme, and in epileptic 
acme. Epileptic acme ; ifs phases. Clinical càaracters qf 
hysterio-epileptic acme. Gravity qf certain exceptional cases 
of hystero-epilepsy . Case recorded hy Wunderlich. 

Gentlemen, — In the brief clinical description which I gave you, 
in référence to eacli of the patients who had passed under your 
observation at our récent conférences, I studied to bring ont the 
principal cliaracters presented by the convulsive seizures to which 
they are subject. 

You hâve been able to recognise, with ease, that we hâve not hère 
to deal with common attacks, which can be assigned at once and 
without discussion to the classic type. Nor is it merely by their 
great intensity that thèse convulsive phenomena are distinguished, but 
also by the form they assume; and what most strikes the observant 
witness is to lind amongst the clonic convulsions of hysteria, 
certain more or less marked features which recail the phenomena of 
epilepsy. 

In point of fact, the convulsive form of disease which is found 
in ail thèse cases, is that whicli lias been designated, in thèse 
latter times, by the name of hystero-epilepsy ; and, remembcr, it is 
the only form met with in thèse patients. Thèse women would not, 
therefore, be simply hysterical patients, they are ail hystero-epilep- 



HYSTEEO-EPILEPSY. 301 

tical. In wliat respect do they clifFer from ordinary liysterical patients? 
This is a question concerning whicli it is important to hâve a clear 
understandingj and in order to secure tliat objecta I request your 
permission to treat the matter at some leugth. 

I. 

If we keep to the terms of the dénomination generally employed — 
Itystero-epilepsy — it would appear as if no misunderstanding could 
arise. It signifies that in patients^ so aft'ected, hysteria is présent in 
combination with epilepsy, so as to constitute a mixed form, a kiud 
of hybrid composed half of hysteria and half of epilepsy. But 
does this appellation, in reality, accurately interpret the phenomena ? 
Superficially looked it, it would seem to do so, since we hâve recog- 
nised in the seizures some of the features of epilepsy. This, m fact, 
is the manner in whicli most modem authors appear to understand 
the term. According to their view, hystero- epilepsy would be a 
mixture, a combination of the two neuroses, varying in proportions 
in différent cases; it is not epilepsy alone, nor hysteria alone, but 
both together. 

Such, I repeat, is the most popular doctrine. However, it is far 
from being universally accepted, and the camp of its adversaries still 
reckons many adhérents. Thèse refuse to admit the legitimacy of 
this hybrid, half- epilepsy, half-hysteria. They do not, indeed, deny 
that epilepsy and hysteria may co-exist in the same individual. The 
most superficial observation would protest against any such assertion. 
There is nothing to authorise the belief that thèse diseases are antag- 
onistic, and it might even be possible, though it has not been proved, 
that patients affected by one of them, might by that very fact be pre- 
disposed to contract the other. But, under such circumstances, it 
is added, the convulsive accidents remain distinct and separate, 
without exercising reciprocal influence over each other, in any marked 
manner, and, above aU, without mingling confusedly so far as to 
justify the création of a mixed intermediate species, in one word, of 
a hyhrid. 

What, then, according to this view, is the signification of those 
attacks, the existence of which is so clearly established by the very 
cases that form the foundation of our study, and in which epilepsy 
seems mixed up with the ordinary symptoms of convulsive hysteria ? 

Epilepsy would, in their opinion, èe présent hère only in the ex- 
ternat manifestation ; it would not be substantially existent. In 



303 EPILEPTirOEM HYSTERIA. 

other words, we would hâve, in tliese cases, hysteria solely and 
always présent, taking on it the semblance of epilepsy. The term 
epilepUform h?/stena, which, if I err not, Louyer Villermay was one 
of the first to employ, would serve to designate thèse mixed attacks. 
The convulsion, epileptic in form, would hère appear, as it appears 
in so many other affections of the nervous system, as an accessory 
élément, without altering in anything the nature of the original 
disease. 

II. 

That, gentlemen, is the thesis to which I give my entire adhésion. 
It has already been maintained by some most compétent authorities. 
Of them, I may cite Tissot, Dubois (of Amiens), Sandras, and M. 
Briquet, who are very explicit on this question. '^Hysterical seizures," 
says M. Tissot, "sometimes closely resemble epilepsy. Hence, they 
hâve been classed as a particular form of hysteria, under the name 
of epileptiform hysteria. But, nevertheless, thèse seizures hâve not 
the true characters of epilepsy ."i 

M. Dubois (of Amiens), considers epileptiform hysteria, as hysteria 
with an extra degree of intensity superadded to its syraptoms," 
Sandras expresses a similar opinion.^ 

M. Briquet, wliose article on this subject bears the mint-mark 
of the soundest observation, says that this species of hyderia, toitlt 
mixed attachs, is only a particular form of hysteria — is simply very 
intense hysteria, — the prognosis is not essentially modified : the 
nature of the cause which occasioned the hysteria and certain con- 
ditions spécial to the affectée! individual, account for the modifica- 
tions observed in the form of seizure. The nature of the hysteria 
is not, itself, radically altered. 

Be good. enough to remark, gentlemen, that this is something 
more than a mère question of words ; it is a question also of no- 
sology, and cousequently, a question of diagnosis and of prog- 
nosis. Thèse circumstances will I trust, suffice to justify in your 
eyes the détails on which I am obliged to enter, in order that the 
conviction which I entertain may take its place in your minds. 

III. 
Let us, therefore, enquire upon what basis the prevailing doctrine 

^ Tissot, ' Maladies clos Nerfs,' t. iv, p. 75. 
- Dunant, ' De l'Hystcro-Epilepsie/ p. 11. 
^ Sandras, ' Maladies Nerveuses,' t. i, p. 205. 



HYSTERO-EPILEPSY. VAPJETIES. 303 

reposes. Hysteria and epilepsy, it is alleged, may be combined in 
différent ways in tlie same patient. M. Beau, who studied in this 
hospital, states tliat he found this combination in 32, ont of 276 
patients. It takes place in différent modes^ and tlie foUowing caté- 
gories may be legitimately established. 

A. In tlie first group, the hysterical seizures and tlie epilcptic fits 
remain distinct ; this is what M. Laudouzy proposes to call hystero- 
epilepsy with distinct crisis. WeW, gentlemen, that would be the 
most fréquent form, seeing that 20 out of the 32 cases reported by 
M. Beau belong to it. Two sub- divisions, however, should be estab- 
lished in this species : 

1°. Epilepsy is the primary disease : upon this stock hysteria 
becomes grafted in due time, that is to say, most frequently at the 
period of puberty, under the influence of certain causes, and of moral 
émotions in particular. 

A case which M. Briquet quotes from Landouzy deserves to be 
summarised for your instruction as bearing upon this point. A 
young woman, who had been affected with epilepsy from her child- 
liood, got married at the âge of eighteen. The disease, which she 
had concealed, soon sliowed itself. Hence arose vexations disputes 
which eiigendered hysteria. The attacks, proper to the two neuroses, 
were separate and preserved their spécifie characters, without either 
being influenced by the other. A reconcihation having taken place 
on accouut of her pregnancy, between the patient and lier hu^band, 
domestic peace was re-established which caused the hysteria to cease, 
but the epilepsy persisted. 

2°. At other times, epilepsy is superaddedto hysteria. This con- 
dition appears to be much rarer than the preceding. M. Briquet, 
liowever, reports a case which came under his own observation in 
which the attacks were distinctly separate. The mind becomes ob- 
scured, in the long run, in patients belonging to this class, owing 
undoubtedly to the influence of the epilepsy. 

3°. Some other combinations, of a secondary order, hâve been 
mentioned. Thus : 

a. Convulsive hysteria co-exists with minor epilepsy^ (Bea«, 
Dunant). 

' The peiii mal of Freiich autliors. This form of the disease, so distinct 
from the common form, to which the name epilepsy is popularly applied, and 
yet so important in itself, especially when questions of liereditary prédispositions 
arise, seenis to deserve a distinct désignation. (S.) 



304 HYSTEEO-EPILEPSY. VARIETIES. 

l. Convulsive epilepsy is superadded to soine of the phenomena of 
non-convulsive hysteria, e. g., contracture, aneesthesia, &c. We 
hâve a case of this kind among our patients. 

But thèse différent combinations alter nothing in the essence of 
things. Most frequently the two diseases, in hystero-epilepsy, exist 
simultané ou sly and proceed their several ways, Avithout reacting on 
each other in any serious manner, each of them preserving its own 
characteristics and proper prognosis. With respect to this first form 
of hystero-epilepsy ail authors are agreed. The second form only 
is concerued in the debate. 

B. In this form, the hysterïa and the epilejjsy are coeval ; they 
both develope at the same time. Hère the crises do not remain dis- 
tinct; they hâve never been so. From the outset, the intermingling 
had been effected, and^ in subséquent attacks, the two convulsive 
forms will always show themselves combined, though in varying 
proportions, without being ever, at any moment, completely dis- 
severed. 

To this condition the name of hjstero-epilepfiij îv'ith comhined 
crises bas been given. In the technical jargon long employed in 
the spécial wards of La Salpêtrière, thèse crises, in such cases, are 
called '' attaques-accès " (which we may translate " seizure-fits "). 

IV. 

Is there really any epilepsy in thèse mixed crises ? Such is the 
question which we hâve now to discuss. With this view, it is right 
that we should take the description of hystero-epilepsy with mixed 
crises, as agreed upon by authors, and examine it under ail its 
aspects. From M. Briquet, in especial, I borrow the description of 
the seizure-fit. It seems to me to be in complète concordance with 
the results of my own observation. 

a. From the outset, the mixed attack assumes its proper character ; 
from that moment, it is epileptiform hysteria. I would recall to 
your memory the patient Etch — , who, in her first attack, fell 
into the fire, and injured her face.^ 

b. The hysterical aura, such as we hâve described it, always con- 
stitutes a premonitory symptom. This aura, generally of long 
duration, occupies the abdomen, the epigastrium, — at ail events, it 
does not affect the head alone from the very first, nor one of the 

' Lecture XI. This patient is also mentioned in Lecture IX. 



HYSTERO-EPILEPTIC ATTACK. 305 

extremities, as takes place in ejiilcps^ with aura. Ilence it is per- 
fectly exact to say that patients suffering from hystero-epilepsy with 
mixed crises are nearly always forewarned in sufficient time to 
enable them to take précautions or to seek a place of refuge, when 
thé fit is coming on. 

c. In the convulsive attack, the so-called epileptic phase generally 
présents itself first, to open the scène. The drama begins — a sudden 
shriek, extrême pallor, loss of consciousness, a fall, distortion of the 
features — then tonic rigidity seizes on ail the members. This rigidity, 
remark it well, is rarely followed by the clonic convulsions, brief 
in duration, limited in oscillation, predomiuating on one side of 
the body, such as we see them in true epilepsy. Nevertheless, the face 
may become greatly tumefied and violet-coloured. Tliere is foam- 
ing at the mouth, and the foam is sometimes bloody on account of 
the tongue or lips having been bitten. Finally, gênerai relaxation 
of the muscles may follow, \Yith coma, and stertorous respiration 
during a less or greater length of time. 

d. To this first phase, which I repeat is the one chiefly concerned 
in the dispute, the clonic pli ase succeeds. Then ail is hysteria : great 
gesticulations, having a purposive character, supervene, and some- 
times violent contortions are made, characteristic of the most varions 
passions, such as terror, hatred, &c.i At the same iimç, paroxi/smal 
■delirium breaks out. 

e. The termination of the attack is marked by sobs, tears, laugh- 
ter, &c. 

Thèse différent phases do not always succeed each other in so 
reguîar a manner ; they get entangled occasionally, and now one, now 
the other prédominâtes. In the patient C — , for instance, the 
tonic phase prevails to a great extent over the other, and sometimes 
it is almost exclusively manifested. 

V. 

We hâve arrived, gentlemen, at the critical point. In what does 
this hysteria with complex crises difFer from ordinary hysteria, if it 
be really separate ? In what does it resemble true epilepsy, if there 
be reason for such an approximation ? 

Is the appearance of tonic convulsions a novel and unwonted fact, 
in the classical description of the common hysterical attack? Certainly 

' See antt', figures 19, 20, and 21. 

20 



306 EPILEPSY AND HYSTEEO-EPILEPSY. 

not. It is not really exceptional, in common hysterical attacks (when 
no one thinks at ail of interpolating tlie epileptic élément), to see 
the supervention of tonic convulsions occur, having an epileptiform 
character, especially at the beginning of the seizure. Ail autliors are 
agreed upou this point. Thèse convulsions are occasionally so marked 
that M. Briquet has been induced to establish, side by side with the 
clonic or classic hysterical seizure, a species of seizure in which 
semi-tetanic stiffness prédominâtes in the body and members. 
Does it not, therefore, seem already probable that the so-called epi- 
leptic form is, properly speaking, only the exaggeration, the highest 
degree of development of this varïety of common hysteria ? 

YI. 

If, on the other hand, we turn our gaze upon true epilepsy, we 
shall meet with a certain number of characteristic peculiarities, of 
which we can easily make profitable use. 

We should point out, in the first place, that, according to the de- 
scription already given, the epileptic type is never represented in the 
seizure-fîts, save in an imperfect manner, in rough outline as it were ; 
but, indeed, that alone would not be a décisive argument. Hère is 
a more significant character. 

Never, in descriptions of hystero-epilepsy with mixed attacks, do 
you find mention made either of the petit mal, or of the epileptic 
vertifjo. AYe might also add, as supplyiug material for an important 
distinction, that, in this form of hystero-epilepsy, even the most 
intense epileptiform attack is, judging from our own observation, 
modified and sometimes even arrested in its development by com- 
pression of the ovary. This never happens in true epilepsy, as we 
hâve over and over again assured ourselves by experiment.^ 

In cases of mixed attacks, even when frequently repeated, it is 
acknowledged by authors, that obnubilation of the intellect and 
dementia are never the conséquences of thèse seizures. This is 
contrary to what would almost necessarily follow, if epilepsy were 
really in question. I cannot dobetter, in connection with this, than 
recall to your mind the case of the patient Ler — , who, for ncarly 
forty years, has been subjeot to the most violent epileptiform hys- 
teria. This woman is, no doubt, odd, and whimsical in her ways, 
but her intellect remains what it was at the outset. The information 

' V. untl. Lecture XI. 



EPILErTIC ACME. TEMPERATURE. 307 

we hâve receivecl, on inquiries made^ do not permit the survival of 
any doubt as regards tliis fact. In sliort^ in cases of this kind, the 
prognosis is nothing différent froin that of intense hysteria. Such. 
is likewise the opinion of M. Briquet. 

Trom this considération a practical conclusion is deducible_, well 
calculated to command jour attention. 

There is, lastly, another characteristic on which I beg leave to dwell 
at some length, because it has not hitherto been noted, so far as I 
am aware, and because, in my judgment, it is décisive. This charac- 
teristic is yielded by thermometrical exploration ; and I hasten to seize 
the opportunity which présents itself now of showing you, by a new 
example, the advantage which may be derived from this mode of in- 
vestigation in the clinical treatment of diseases of the nervous system. 

It is not, gentlemen, that the tonic epileptiform convulsions of hys- 
terical patients differ, in any respect, from the convulsions of the epi- 
leptic attack, so far as changes of central température are concerned. 
The tonic hysterical seizure, if it hâve but a certain intensity, raises 
the température by i° C, (=i*8° T.), nay, by a degree and some 
tenths (38°, 38-5° C.,= 100-4° l'v I0i'3° 'F.), exactly as we find to 
resuit from an attack of true epilepsy, This is a fact the accuracy 
of which we hâve had many opportunities of testing in thèse wards." 

But if, as regards thermie élévation, the attack of epileptiform 
hysteria and the attack of true epilepsy be identical, it is quite 
otherwise when we hâve to deal with those fast-following fits that 
constitute what, as regards epilepsy, hâve been called in France 
les séries or etai de mal (= statîis epilejjtictis, — which we may 
translate by the term ejùleptic acme). 

Of this epilepiic acme we can distinguish two kinds : the minor 
acme, {les petites séries), constituted by from 2 to 6 fits, and the major 
acme, (les gratides séries), in which from 20 to 30, or even more fits, 
hâve been reckoned in the twenty-four hours. I address myself ex- 
clusively to the latter, because the phenomenon, on which I wish to 
lay stress, then manifests itself in its typical state of full develop- 
ment. In such cases, gentlemen, that is to say, when a great number 
of true epileptic fits succeed each other, within a brief space, the 
central température becomes remarkably augmented ; and, most 
assuredly, this thermie increase cannot be attributed exclusively to the 
répétition, any more than to the intensity, of tonic muscular contrac- 

ï Bourneville, ' Etudes Cliniques et Thermomètriques sur les Maladies dm 
Système Nerveux.' 



308 



EPILEPTIC ACME. TEMPERATURE. 



lions, for tlie convulsions may completely cease for several days, 
•whilst tlie température nevertlieless persists^ during this time^at a very 
'higli élévation. 

We can observe and foUow thèse peculiarities on the diagram 
•wliich I place before you, and wbich represents the changes of central 
température in the patient Cheval — , during the course of the 
■ejnlejjtlc acme which she has recently experienced. (Fig. 25.) 



Jours] 1 



2 3 4 


5 6 7 8 j 


i 


'\ 1 r 



I 



W.l 



: -ir-f- 



\ 1 ■ 1 




r 


Aï 




u 


! 

1 




■in^ 






r 


.: 


1 ' 
i 






; 


i 


BH 


1 



FiG, 2 15. — Température (C) taken shortly after the eleventh fit. rrom the eveniug 
oC the first day uutil the morniug of the second, thirty-one fits occurred. 
+ Température after a remission of four liours. After this the fits 
take place at greater intervals, and cease on the third day. The dotted 
Une represents the state of the puise. 

It must be borne in mind that this élévation of température is, 
in the great raajority of cases, even after complète cessation of the 
convulsions, an omen of the darkest significance. It is, besides, 
most frequently accompanicd by a gênerai state of the constitution 
whicli, of itself, gives much cause for appréhension. Thus, some- 



HYSTERO-EPILEPTIO ACME. 309 

times, a more or less marked delirium exists, whicli M. Delasiauve 
attributes to meningitic congestion ; sometimes, on the contrary, 
a more or less profound coma — the apoplectiform congestion of 
authors — is found. In both cases we observe great prostration, dry- 
ness of the tongue, teudency to rapid sloughing over the sacrum ; 
lastly, occasional production of transient hemiplegia, the cause of 
wliich has not, as yet, been revealed by any post-mortem examina- 
tion. 

However, and this is a most important datum to note, this éléva- 
tion of température, even when it exceeds 41° C. (= io5'8° F.), and 
is accompanied by the grave symptoms just enumerated, is not to 
be regarded as a sign necessaril^ heralding a fatal termination. You 
perceive by the record of Chevall — , that a patient may still 
recover, even from the midst of ail thèse grievous circum stances. 
Augmentation of température above 41° C.(= io5'8° F.) is not, there- 
fore, necessarily terminal in such cases ; consequently, the assertions 
published by Herr Wunderlich, and after him by Herr Erb, in relation 
to this point, must be subjected to abatement.i 

^ The case of the patient Chevall — is related at full length, up to aôth 
March, 1872, ia our ' Etudes Cliniques et Thermomètriques sur les Maladies 
du Système Nerveux* (Obs. xxxiii, p. 285). Since that period, Chevall — ■ 
Edmée has been seized with new accidents issuing in a fatal termination. We 
think it ail the more useful to relate them hère because, besides completing 
the former record, they sapply additional proof in corroboration of the opinions 
stated by M. Charcot in the présent lecture. 

1873, Febmaij 9. — For about a week Chevall — has been tetchy and 
irritable; sometimes she has been so violent that constraint was necessary 
(maniacal excitement). 

Tehruary 10. — Last niglit the agitation augmented; Chevall — prevented 
the other patients from sleeping, by her cries. She, however, became calm 
after three o'clock a.m. Three fits were noted during the night. From one 
o'clock p. m. till three o'clock p. m. the fits multiplied. At three o'clock : puise 
100; rectal température, 38"6° C. (=:ior48° F.) 

Tehruary 11. — Yesterday, from one o'clock till nine o'clock p.m., forty- 
three fits were counted ; and from that until seveu o'clock a.m., seveuty fits ; 
from seven o'clock till eleven o'clock a.m., when this note was taken, there 
occurred thirty-five fits. The foUowing is a description of the fits : 

Five or ten seconds before their occurrence, the pupils (especially the left) 
became widely dilated. Sometimes, in addition, we hâve little complainings, 
grinding of the teeth, and, exoeptionally, a slight cry. The fit begins : the 
eyeballs are subject to very marked convulsive movements (nystagmus) ; the face 
grows pallid, and is deviated to the left ; the gaze, at first fixed and direct^ 
is averted to the left. The left arm rises, and then stifFens, simultaneously 



310 HYSTERO-EPILEPTICAL ACME. 

I should remiiid you, in passing, that this rapicl increase of tem- 
pérature is far from being the exclusive appanage of tiie epi- 

with tlie riglit, wliicli, however, rests upon the bed. The tétanie stifTuess next 
invades the lower extremities. At the end of a few seconds, we notice semi- 
occlusion of the left eyelids, which are agitated, like the muscles on the same 
side of the face, by rapid convulsive movements. 

Ten to fifteen seconds after, the face and eyes turu to the right ; the body 
inclines to the right; the left eyelids open, and remain nearly niotionless ; but, 
to make up for this, the convulsions seize upon the right eyelids and the 
muscles of the right side of the face. The mouth, at first drawn to the 
left, is now drawn to the right. The clouic convulsions mauifested during 
this phase, which had at first invaded the members of the left side, now pre- 
dominate on the right. 

Finally, the fit concludes by snoring, extrême lividness of the face, and 
foaming at the mouth. At the elose of the fit, the pupils résume their normal 
dimensions. 

During the remissions the patient is in complète resolution. When raised 
and let go the limbs fall inert. Energetic pinching provokes a slight raising of 
the left arni, but nothing in the right. When the soles of the feet are tickled, 
reflex movements are set up, which are more intense ou the left than on the 
right. The right eje is uot injected, whilst considérable hyperœmia of the lower 
half of the left eyeball and a lesser vascularisation of the lower lid exist. The 
nostrils are pulvérulent. The digestive tube présents no particular symptom ; 
there was a stool after euema yesterday ; Ch — micturates in bed. Erythema- 
tous patch on the left gluteal région, profuse perspiratiou, augmeuted at inter- 
vais. At eleven o'clock : puise 120 : respiration 49, noisy ; rectal température, 
40'8° (=io5'44T.). At noon puise 130 ; respiration 60. 

Six 0' dock p. m. — Seventy-six fits hâve been noted since eleven o'clock a.m., 
of which thirteen occurred after half-past four o'clock p.m. Respiration 60 ; 
rectal température, 41 "3° C. (^io6'34° P.) Copions perspiration over the 
whole body, on both sides indifferently. The entire left side of the body 
(face, trunk, &c.) is plainly warmer than the right. 

The eyelids are half-opeu ; the eyes turned up ; the pupils are moderately 
dilated (the right still the more enlarged). Before every fit, dilatation of the 
pupils augments in a remarkable manner. The nystagnms seems to appear 
almost simultaueously. Neither vomiting, nor stools, nor micturitiou. Same 
condition of right gluteal région. Coma. Stertorous breathing. 

Bight d dock p.m. — Puise — ; respiration 70 ; rectal température 41 "a" C. 
ï"ourteen fits. From this time forth the patient had no more fits. She died 
at three o'clock in the morniug. Vaginal température (taken by another) was 
4i'2° (=ioi'io° F.). At eleven o'clock in the moruing ou the iith February, 
i.e., eight hours after death, rectal température 40°. (^104° F.) (the corpse 
remaining in the bed). The pupils are moderately dilated, and both equally 
Numerous livid stripes or whcals on the belly, back, buttocks, and thighs. 

Post-mortem, Feb. 18. — The bones, dura mater, and sinuses présent nothing 
abnormal. The quantity of cephalo-rachidian liquid is not augmented 



TEMPERATURE. 311 

leptic acme ; it is likewise observed in the so-called congestive, 
apoplectiform, or epileptiform attacks of progressive gênerai para- 
lysis, as was first pointed out by Herr Westplaal, who lias, how- 
ever, offered an interprétation of the fact which is little in con- 
formity witli the reality.^ It is also observed in the very similar 
attacks which may supervene in the course of disseminated sclerosis,^ 
and, lastly, in the attacks accompanied or not by convulsions 
which take jjlace in cases of old cérébral foci (hœmorrhage or 
ramollissement) or of cérébral tumours, whatever their origin. 
This thermie increase contrasts, in a remarkable manner, with the 
initial decrease which almost always exists at the moment of the 
formation of a cérébral hasmorrhagic focus, — and that, as I hâve 
demonstrated, is a characteristic which may be profitably used in 
making a diagnosis. 

But it is time to return to epileptiform hysteria, from which this 
digression has somewhat separated us. Complex fits are observed in 
hystero-epilepsy precisely as in true epilepsy. Landouzy speaks of 
one hysterical patient who had up to loo fits a day. The hjstero- 
epileptical acme may, besides, be prolonged over a considérable space 

Sanguineous suffusion on the couvex surface of the cérébral hémisphères, 
especially on the right. Arteries, at base of brain, healthy. Weight of 
encephalon, 1360 grammes. Tlie pia mater is very slightly injected at base of 
brain ; most marked at the sphenoidal lobe. The pia mater is easily detached 
ou both sides, and the brain is equally moist. 

Bight hémisphère. — It weighs 5 grammes (=77-17 grs.) more than left. On 
certain couvolutions, chiefly those lying adjacent to the Sylvian fissure, we note 
a hortensia coloration, some little abrasions, and, on a few, a very fine red 
punctuation. The convolutiou of the cornu Ammonis présents a very évident 
induration. This induration, which asceuds interiorly along the said couvolu- 
tion, prédominâtes at its extremity. 

Left hémisphère. — The cornu Ammonis présents an induration much less 
marked and circumscribed at its extremity. 

Nothing notable in the cerebellum and isthmus. 

Spinal conl. — The grey substance, viewed with the naked eye, seems a little 
deformed. 

Thora.v. — Considérable congestion of the lower half of the lungs. There is, 
moreover, a focus of red, récent hepatization iu the lower lobe. 

Heart, stomach, spleen. — Healthy ; no ecchymoses. Liver, not congested. 
Kidneys, anaemia of cortical substance ; pyramids distinct. Bladder, nothing. 
Utérus, fair size ; récent corpus luteum on one of the avaries ; small cysts 
on the other (B.). 

1 Westphal, loc. cit. 

2 V. antè^ Lecture VIIT. 



312 



TEMPEEATUKE. 



of time. Georget quotes the case of a woman who suti'ered from 
an almost continuons succession offits extending over forty-five days. 

In the case of our patient Co — , whose seizures bear such a pré- 
dominant and strongly-marked epileptiform cliaracter, ihe parojc^s- 
mal acme persistecl over ttvo months, and, at times, the accidents 
attained the highest degree of intensity. Thus, to mention one 
instance, on the 32nd of January, the epileptiform convulsions 
followed each other, without interruption, from nine o'clock in the 
morning until eight in the evening ; from eight until nine o'clock 
there was a resting space, after which the attacks came on again, 
as though with renewed vigour, and persisted, without the least lucid 
interva], for about the same length of time. We may without any 
exaggeration calculate that, in round numbers, she experienced from 
150 to 200 epileptiform fits in the space of a day at that period. 

Does not the persistance of such a state, without a fatal termination, 
already indicate by what an abyss true epilepsy is separated from 
hystero-epilepsy ? " If that were not hysteria,^"" said the experienced 
head nurses of thèse wards, speaking of Co — , whose seizures they 
watched, " if it were really epilepsy, the woman would hâve suc- 
cumbed long ago/' This remark is thorouglily well-founded and 
perfectly correct. 

Well, gentlemen, hère is the point upon which, especially, I wish 
to lay stress, — never, during that long convulsive period, was the 
rectal température modifîed in a perceptible manner, in the case of 
Co — 3 on an average it stood at 37*8° C. (= 100*4° P.)j i^ o^y 
rose tp 38*5° C. (= 101 '3° P.), in a quite exceptional and transient 
manner. (Fig. 26.) 



19 20 21 22 23 24 25 26 



■PPw 



FiG. 26. 
I should add that, during ail this tiinc, the gênerai condition of 



TEMPEKATURE. 31^ 

the patient uever gave us tlie least uueasiness, in spite of the insuffi- 
ciency of her alimentation and the enormous amount of muscular 
force she must liave expended. Again, her mental condition was, by 
no means, so deeply modified as it would necessarily hâve been if 
the disease had been true epilepsy. At no period was there invo- 
luntary évacuation of urine or faîces. In the brief respites allowed 
her by the fits, the patient rose to satisfy the requirements of 
nature. In thèse intervais, also, which were in truth very brief^ 
the hysterical character of the disease showed itself in ail 
its fulness, especially during the first weeks. A flower twined in- 
her hair, fantastic curls, an old bit of mirror attached to the bed- 
post, — thèse things suflficiently attested the favourite occupations of 
this woman during her intervais of ease. 

But I désire, above ail, to call your attention to the thermal 
state which careful investigation enabled us to discover. It would, 
in short, follow from what précèdes that, whilst, in the major 
acme of epilepsy, the température rises very rapidly to a high 
degree, and the position of affairs becomes extremely critical, — in 
the viajor acme of Jii/stero-ejnlepsi/ on the contrary, the tempéra- 
ture rarely exceeds the normal standard, whilst the concomitant 
gênerai state of the patient is not of a kind to inspire uneasiness. 
It is not necessary, I think, to dwell at any length upon this topic 
in order to emphasise so striking a contrast. 

I do not, however, gentlemen, want you to take in its strictly 
literal meaning the last term of the proposition which I hâve just 
euunciated ; it undoubtedly applies accurately to the great majority 
of cases, but the chapter of exceptions exists. It would not, in 
fact, be unexampled to find hysteria terminating in death during the 
convulsive phase. It is true that this sad resuit is nearly always 
owing to a peculiar kind of attack, the dyspnœlc seizure} But I 
repeat, the convulsive fits may themselves be the cause. As an 
example, I may remind you of a case of this character published by 
Herr Wunderlich.^ It relates to a case of hystero-epilepsy, compar- 
able in many respects to that which I hâve just described. 

The patient in question experienced epileptiform attacks for more 

' Briquet, loc. cit., pp. 383 et 538. 

" The foUowing is a translation (after M. Teinturier) of Wunderlicb's case, 
to which M. Charcot alludes : 

Note. — Eight weeks of apyretic hi/steriform convulsions, without apparent' 
danger. Suddenand déplorable change, icithout augmentation of paroxysmal in^ 



314 HTSTERO-EPILEPSY. FATAL CASES. 

tlian eiglit weeks, though in number they were somevvliat limited, 
and not accompanied by any niarked augmentation of température, 

tensity. Beatli in tlie course of a few Jiours, witli a température of 43° C. 
(=109-4° r.) 

Post-rdortem. — Auna Vogel, œt. 19, servant, Lad twice menstruated in the 
fortuight before falling ill, but otherwise in good bealth, was taken with con- 
vulsions, for the first time, on tbe I3th August, 1855, after a severe scolding, 
according to her own account. The convulsions came on agaiu, iu the evening 
of the I7th, and in the morning of the i8th, and continued almost uninter- 
ruptedly throughout the night, from the iSth to the ipth. Admitted at noon 
on the I9th. She presented at midnight slight subsultus in the left arm, in 
which the présence of paralysis without iiisensibility had been noted. Then 
she experienced a feeliug of anguish (coustrictiou in tbe epigastrium), gave 
a slight cry, and had convulsions, first iu the left half of the face, and then in the 
right also ; the mouth was open, the eyelids were alternately opeued and closed, 
the eyeballs turned greatly upwards. Then supervened violent aud rapid clonic 
convulsions in the lower extremities aud pelvis, by which thèse parts were 
projected forward, backward, and sideways. The face was cvauosed, and foam 
llowed from the mouth. At the end of a minute, deep and superior breathiug ; 
relaxation of the limbs and face. Afterwards sleep, appareutly peaceful; 
lastly, yawiiiug, opeuing of the eyes, and return to consciousness after six 
minutes. 

The patient is in good condition, her tongue islittle loaded ; the température 
is 38"i2° C. (=iioo*6° P.), the puise 140 (after the fit) ; nothing abnormal. She 
says, however, that she cannot move her left arm, and requests that it shall 
not be touched, because otherwise she will get convulsions. Nevertheless, she 
can grasp sti'ongly with the left liaud. 

In the night of the i9-2oth, six seizures ; aud iu the day foUowing, seven 
seizures. No albumen in the urine ; considérable uric sédiment. Tongue 
loaded. Température, morning and evening, 38' 12° C. (=ioo'6°r.); puise 
132 ; respiration 24 — ■32. In the night of the 20-2 ist, seven seizures ; thirteen 
seizures till the morning of the 22nd. Température, 3776° (= 99*96° F.) ; 
stools normal ; urine slightly turbid from the présence of albumen. 

From eight to sixteen fits a day, in the following days. Condition otherwise 
tolcrable; no marked élévation of température, which is generally normal, 
never above 38-i2'-'C. (=ioo'6° F.), except one evening, when it reaehed 
38-75" (=:ior75" F.); puise usually above 112; tongue loaded. On the i6th, 
confluent vesicular miliary eru{)tiou on the fînger tips. Urine charged with 
phosphates, without albumen. Duriug the seizures she sometimes loses con- 
sciousness, somctimcs not; occasionally shrieks greatly. Sensibility persists in 
the left arm and leg. 

']th Septemher. — The fits become more fréquent, last several days without 
interruption ; during the seizures she often talks and shrieks. Fréquent évacua- 
tions of urine and fa;ccs in l)ed. Improvemcnt, then stationary condition until 
the evening of the 2nd (Jctober, when the patient présents a niarked attack 
of collapse. h\ the night of the 3rd no particular seizures. In the morning 



HYSTERO-EPILEPSY. FATAL CASES. 315 

wlien suddenly — witliout known cause, without the intervention of 
new accidents — the scène clianged two days before death ; tlie patient 
fell into collapse, and in a short space of time the température rose 
to 43° ( = 109-4° F.). 

This example, gentlemen, will sufïice to show you that, in présence 
of a case of hystero-epileptic acme, whatever be its intensity, or 
however great the chances of a favourable issue, it would be im- 
prudent to abandon ourselves to a feeling of complète and absolute 
security. 

agitation of the arms and divergent strabismus. The head inclined forward 
and to the left ; consciousness proserved ; slight oyanosis. From ten o'clock 
fortb, déglutition impossible ; at noon, trisQius ; at a quarter to two o'clock, 
strong convulsions, not afFectiug the head ; puise extremely fréquent ; tem- 
pérature, 4i'87°; intense cyauosis, foaming at the mouth ; trachseal râle. Died 
at a quarter past two o'clock; température, 43*1° C. (=109*58° F.). A 
quarter of an hour afterwards, température 42'75° C. (=io8"95°F.) 

Post-moriem. — Body in good condition ; large cadaveric spots in the lower 
parts ; no muscular rigidity. The crauium and its contents gorged witb blood ; 
posterior convolutious slightly flattened ; cérébral substance rather hard. 
Slight turbid thickeuing of the pia mater at the base of brain. Capacity of 
cérébral cavities uearly normal, parietes usual consistence. Pons and medulla 
injected with blood, dirty greyish red. Lungs congested and œdematous. 
Hearù normal. Lioer fatty hère and tliere, exsanguine ; bile, clear and dark 
brown. Spleen, sraall, soft, pale brown, exsanguine. Stomach dilated, otherwise 
normal, as were the intestines. Kidnei/s greatly gorged with blood ; concrétion 
size of half a pea in calyx of left kidney. Utérus normal. caries containing 
numerous cysts, as large as peas (Wunderlich, ' Archiv der Heilkunde,' t. v, 
p. 210). 



APPENDIX. 



CASE OF PARALYSIS AGITANS. 

[See Plate YIII, which represeuts the characteristic attitude of 
patients affected by paralysis agitans.] 

Antécédents. — Probable cause of disease. Commencement; the mem- 
bers successïvely invaded hy debilïty. Tremor of the head, then 
of the limbs. 

State of the patietit in i?»"]/^; gênerai attitude. Tremor. Gait : 
propulsion and retropulsïon. Température, puise, 8fc. 

Modifications supervening in the disease, frorn July, 1874, 
until July, 1875. ' 

Gav — Anne Marie, set. 62, was admitted to La Salpêtrière, 
December 3ist, 1873; came under M. Charcot's charge (Salle St. 
Alexandre, No. 3), on the lath November, 1873. 

Antécédents. — Her father, a carpenter, died of an accident when 
she was only twelve years of âge. Her mother, who succumbed at 
the âge of seventy-four, was of a nervous disposition, easily moved 
to passion, but had been affected neither by tremor nor by paralysis. 
Her only sister died of pleurisy at forty. None of her relations, 
so far as she was aware, suffered from nervous affections nor, par- 
ticularly, from tremor. 

Gav — arrived in Paris at the âge of four. Her childhood and 
youth passed without the occurrence of any incident worth noticing. 
Prom the âge of fourteen she menstruated regularly. Having 
married at the âge of twenty-eight, she has had five children. 
Pregnancy and confinement generally favorable. Of the five children, 
the eldest (a boy), died during the Commune, aged '>,^ ; the second 
and third (boys also) enjoy good health ; the fourth, a female, aged 



318 APPENDIX. 

28, is subject to nervous attacks at long intervais ; the fifth died at 
birth. 

The patient assures us that she bas never bad any serious illness ; 
never, for instance, was affected by rbeumatism or chorea. Although 
she had been a costermonger for thirteen years^ she never gave 
way to excess in drink. She bas always lived in healthy lodgings, 
well exposed to the sunshine -, she was happy in her home, and never 
sufFered from any privations. 

Invasion of the diseuse. — Her affection jSrst showed itself in 1868, 
under the foUowing circumstances. Her third son, of whom she 
was particularly fond, unexpectedly told her one day that he had 
enlisted as a soldier. Tbis news greatly afflicted her ; she wept much 
over it, and from the following day was aware of a weakness in her 
right arm. Soon after, the left arm was taken in the same way, then 
the right lower extremity was invaded, and (simultaneously) the left. 
During the nigbt-time she had cramps in her legs which made her 
cry ont. Next she experienced weakness in the loins. At the time 
of her entrance into hospital (December, 1872), she was not so 
weak as at présent (July 8th, 1874). The trembling began to invade 
the members, affecting first the right upper extremity, in the early 
months of 1873. Lastly, she noticed about the same time that she 
was affected by retropulsion ; one day, having missed her step, she 
felt herself compelled to walk backwards in spite of herself. 

Présent state{^xi\^ 8th,i 874) . — The gênerai attitude of the patient, 
when standing, is that described by M. Charcot in Lecture V, and 
which is so faithfully depicted on Plate VIII, by M. P. Eicher. 
The body and head are bent forward ; the neck is stretched and the 
head seems as though fixed on a rigid stem. The features are quite 
immobile ; the brow is but faintly marked with wrinkles ; the eye- 
lids are moderately open ; the patient can, however, raise or lower 
them with ease. The eyes, but slightly expressive, are directed 
forward ; the patient must turn her whole body in order to look 
aside. Sometimes the lips adhère, but generally the mouth is half 
open, the lower lip, relaxed and hanging, allows the dental arch to 
be seen, the saliva flows involuntarily, The lips and tongue do not 
tremble. Déglutition, it appcars, is almost always laborious. 

Thcarms are held slightly apart from the chest ; the fore-arms, half 
flexed, are so placed that the bands rest on the umbilical région, 
whilst the clbows are somcwhat apart from the body. The thumb, 
slightly inflexcd, rests usually on the forefinger ; the other fingers 



APPENDIX. 319 

are slightly bent and gathered togetlier. Botli bands are disposed 
in the same manner. 

The legs approximate, though tbc knees do not toucb. If tbe 
legs are separated, the equilibrium becomes uncertain. Whether the 
eyes are open or closed the attitude of the patient is the same. 

She sits down heavily, and ail of a sudden, She cannot rise until 
she get assistance, and even then the attendants hâve to use strength 
to raise her. After hesitating, she begins to walk, advancing first 
with short steps, afterwards hurriedly, — there is propulsion. "Some- 
times/' says Gav — " I ani driveu very far, until I meet a wall, — 
and if I don^t, I fall." The existence of retrojoulsion is also 
marked ; to observe it, it is only necessary to pull the patient gently 
by the skirt, — the method adopted by M. Charcot. Immediately 
she begins to walk backwards, and with such rapidity that she 
would soon fall if not watched. The hésitation of the patient, before 
returniug, is greater than before beginning to walk. 

The trembling is scarcely notieeable, especially when she is at 
rest. The head trembles, at times, a little more than the hands. 
When thèse are hanging by the side, they generally remaiu motion- 
less. The patient can incline her head more than it usually is in- 
clined, but it is impossible for her to raise it in extension completely, 
because " the vertébral column is stifF." 

Neither cephalalgia, nor vertigo, nor giddiness. The intellect is 
preserved and the memory good. Her sleep is less abridged than 
we find to be the case with most patients suffering from the same 
complaint. She would even sleep well if she were not frequently 
waked up by pains in the heel " that prick me, and you'd think 
^twas water running inside the heel."" She complains of a constant 
feeling of heat, and only keeps a sheet over her even in winter time. 

We hâve mentioned the state of her strength, measured by the 
dynamometer (Note to Lecture V) and that of her température, so 
we shall not revert to thèse points. 

July, 1875. — The weahness has goneon increasing, The gênerai 
attitude remains the same ; however, the head and trunk are more 
and more inclined forward ; besides, a sort of latéral inclinatioH lias 
occurred, in conséquence of which the right half of the body pré- 
cèdes the left half in walkhig. 

At présent, the li23S are almost always adhèrent each to the 
other; the upper lip is puckered; sometimes, according to the 
patient, both of them are stifl". The dental arches are not pressed 



320- APPENDIX. 

against eacli other. It would seem as if the patient drew lier lips 
together to diminish the trembling of the cliin ; in spite of this 
précaution, her legs are stirred by little twitcliing movements, whicli, 
to use lier owii words, remind one of the motion of rabbits' lips. 
The longue trembles even within the mouth ; when protruded, the 
trembling is augmented. 

The trembling of the head is composed of antero-lateral, and 
sometimes latéral, shakes, of very limited extent. Thèse oscilla- 
tions are transmitted to the head by the body, as was mentioned 
in the course of the lecture. When the patient is sitting, her legs 
tremble, and her feet beat rapidly on the floor, striking little blows. 
To sum up : — trembling bas progressed, so far as the head and 
lower extremities are concerued ; but in the upper extremities there 
is little altération. Let us also notice that the necessity of changing 
position (fidgetiness), which was little marked in 1874, and was 
only experienced dui'ing the day, is much more manifest at présent, 
and torments the patient not only during the daytime, but whilst 
reposing in bed (at night). Her sleep is less tlian it was formerly. 
The patient still takes exercise in the ward and in the courtyard of 
tbe infirmary (B). 



INDEX. 



A. 

ACHEOMATOPSIA, hysterical, 233, 249, 

277, 282 
ACME, epileptic, 307 

— hystero-epileptic, 276, 309 
Ambltopia, hysterical, 295 

— in disseminated sclerosis, 191 
Amtoteophy, protopathic (w. Ateo- 

PHY, muscular) 

— symptomatic : in hysterical con- 
tracture, 297; of cérébral blood- 
clot, (note) 53 ,• of lieuiilateral lé- 
sion of the cord, 86 ; of dissemi- 
nated sclerosis, 53, 199 ; of latéral 
sclerosis, 52 ; of posterior sclerosis, 
52 

Analgesia, 248, 252, 289 

An^sthesia, its rôle in bed-sore of 
spinal origin, 81 

An&ioneueoses, 112; of hysterical 
patients, 115 

Apoplext, spinal, 55 

Aetheitis deformans, 98 

Aetheopathies of ataxic patients, 6 ; 
symptoms, 96; seat, 97; lésions of 
tiie joints, 98; altérations of cells 
of aiiterior cornua, 100; in pro- 
gressive muscular atrophy, 101 

— of cérébral and spinal origin, 92 

— in traumatic hemiparajAegia, 85 

— of hémiplégie patients : historical 
sketch, 93 ; mode of invasion, 
95 ; lésions, 96 ; cliuical characters, 
96. 

AETicuiiATiONS, trophic afPections of, 

22 (see Aetheopathies) 
Attaques-acces, 304, 305 (v. Seizuee- 

FITS) 

Attack, APOPLECTIEorm, in dissemi- 
nated sclerosis, 204 ; its f requency, 
204, 206. 

— in gênerai paralysis, 204 ; patho- 
geiiesis, 206. 

— in cases of apoplectic foci of okl 
standing, 206; varieties, 204; sym- 
ptoms, 206 ; puise and température, 
207 



Ataxia, iocomotoe, cutaneous affec- 
tions in, 64; relation between thèse 
affections and fulgurant pains, 65 ; 
différences dividing ataxia from the 
tremor of disseminated sclerosis, 
189 ; — in disseminated sclerosis, 198 

Ateophy, muscular, 6 ; consécutive on 
section of the ischiatic nerve, 10 ; 
arthropathies in, 101 
— progressive, 101 ; irritative lésions 
of nerve-cells in, 58 ; tendency to 
become gênera lised, 59 

Atteaction (theory of), 121 

Atjea, hysterical, 234, 266 ; characters 
of, 266 ; first node, or ovarian pain, 
266 ; second node, or globus hys- 
tericus, 266 ; third node, or cepha- 
lic phenomena, 267 ; influence of 
compression of the ovary on, 267, 
271, 272, 275, 277, 278, 281, 306 

AvANT-MUB (see Claustetjm), 256 

B, 

Bed-soee, 69, 114 (v. Decubitus) 

Beomide of camphoe, 156 

BuLBUS EAC^iDiCTTS, muscular lésions 

consécutive on afleetions of, 60 ; 

lésions of, in paralysis agitans, 151 ; 

in disseminated sclerosis, 160, 205 

C. 

Calabae bean in paralysis agitans, 
155 ; in disseminated sclerosis, 221 

Capsule, inteenai, 256 

Capsules, supea-eenal, hsemorrhage 
of, in spinal lésions, 106 

Cells, neeve-, motor nerve-cells in 
anterior cornua of the grey sub- 
stance of the cord, 52; lésions of 
thèse cells : acute form (infantile 
paralysis^, 57 ; chronic form, pro- 
gressive muscular atrophy, 58; rôle 
of motor nerve-cells in the produc- 
tion of trophic troubles, 61 ; yellow 
degeneration of nerve-cells, 180; 
lésions of , in disseminated sclerosis, 
199, 200 ; in hysterical contracture, 
297 

21 



322 



INDEX. 



Ceeebrum, aiiatoinical views concern- 

ing, 255 
Choeda tympani, a dilator nerve, 116 
Chobea, disorderly movemeuts of, 

compared to tremor of dissemi- 

nated sclerosis, 189 (v. Hemi- 

choeea) 
CiCATEiCES, vicious, 21 
CiREHOSis of muscles, 47 
CcELiALaiA, hysterical, 234, 264 
Cl-AUSTETJM, 256 

Compression of the ovary, 271 ; its 
influence on hysterical seizure, 271 ; 
luodus operandi, 271 ; historical 
sketch, 272 

Congestion, apoplectiform and epilep- 
tiform, 309 

CONTEACTiLiTY, electrical, after patho- 
logical and after expérimental 
nerve-lesions, 32; in hysterical con- 
tracture, 297 ; in fractures and luxa- 
tions of the vertébral column, 55 ; 
in hœmatomyelia, 55 ; in acute cen- 
tral myelitis, 54 ; in disseminated 
sclerosis, 179 {v. Myopathies) 

CoNTBACTrEE, 'permanent hysterical, 
233, 277, 279, 283 ; action of chloro- 
form on, 285 ; convulsive tremu- 
lation in, 285 ; hémiplégie form, 
284, 287 ; charaeters differentiating 
it from organic hemiplegia, 287 ; 
hemiparaplegic form, 283,'289, 293 ; 
prognosis, 297 ; sudden recovery in 
sorae cases, 292 ; reputedly miracu- 
lous cures, 293 ; incurable contrac- 
tures, 295; lésions in, 294; patho- 
logical physiology of, 297 

— permanent, in sclérose en plaques 
(disseminated sclerosis), 200 

— tardy, in hemiplegia of cérébral 
origin, 95 

— of the ureters, 243 

CoNVULSiONNAiEES, 249, 274; dcmo- 
niacs, 278 

Convulsions (arrest of), in hysterical 
cases, by compression of the ovai-y, 
271 ; in spinal epilepsy, 275 

COEPOEA OPTO - STEIATA, Icsions of, 

their ciTects, 251 ; French thcory, 
254 ; British theory, 253 

CuERENTS, electrical, dilTerences bc- 
tween continuod and iuterrupted, 
34 {v. Faeawisation) 

Cuises, gastric, 212 

CuTANEOUS diseases, 18, 20, 20, 64 



D. 

Decubitus AcrTus (acute bed-sore), 
69 ; mode of évolution, 70 ; con- 
sécutive affections, 73 ; in apoplexy 
symptomatic of cérébral lésions 
in foci, 76; sciit, 77; pathogeny, 
79, 114 
— of spinal origin, 72, 79; seat, 79; in 
traumatic myelitis, 80; influence of 
position of spinal lésion, 82; in 
traumatic hemiparaplegia, 83; in 
spoutaneous myelitis, 87 ; epoch of 
manifestation, 88; rôle of grey 
substance on its production, 89; 
influence of nerve-lesions on, 91 

Degeneeation, îoaxy, of the muscles, 
47 

Déliée des geandeues, ambitious de- 
lirium in disseminated sclerosis, 195 

DiPLOPiA in disseminated sclerosis, 
191,211 

Dynamometee in paralysis agitans, 
135, 145 

E. 

Ecchymoses, viscéral, in circumscribed 
cérébral lésions (endocardium, 
stomaeh, pleura, bladder), 104 ; of 
the epicranial aponeurosis, 104 ; 
in spinal lésions, 106 

Electeo-diagnosis, 30 

Emboli, gangrenons, consécutive on 
acute bed-sore, 74 

Encephalitis, 76 

Endocaeditis, ulcérons, with multiple 
emboli and typhoid state, 68 

Epidemics, hysterical, 273 ; of St. Me- 
dard, 249, 274 ; of St. Louis, 293 

Epilepsy, its relations with hysteria, 
300, 303 ; description of a fit, 301 ; 
spinal epilepsy in hysterical con- 
tracture, 285, 297; in disseminated 
sclerosis, 201 ; its forms, 202 ; ar- 
rest of, 275, 306 («. Acme) 

Eeuptions, eczematous, 20, 21 ; liche- 
noid and pnstular, 64; pemphigoid, 
21, 27, 91 

Eeythema pernio, 21 

EscHAE of nates, 6 ; of rapid forma- 
tion, 69 ; its position in apoplexy, 
77; in apoplectiform attacks, 200 ; 
sacral, 4 ; in locomotor ataxy, 65 ; in 
epileptic acme, 309 {v. Decubitus) 

Etat de mal, epileptic, 307 ; hystero- 
epileptique, 276, 307 («. Acme and 
Température) 



INDEX. 



323 



ExciTABiLiTT, electrical (histological 
altérations corresponding to diminu- 
tion of), 46 

ExPERiMENTS of Erb, Ziemmseu, and 
O. Weiss, 46 



Fasciculi, internai radicular, 66 ; irri- 
tation of, iu posterior selerosis, 67 

Faeadisation and galvanisation, dif- 
férence of action, 34, 40, 46, 49 ; 
in disseminated selerosis, 221 

Foox (deformity of), in paralysis agi- 
taris, 142 (v. Trépidation) 

— club, hysterical, 294, 298 
Fulgurant pains, 66 

G. 

Gait, in paralysis agitans, 145 

Ganglion, superior cervical (effects of 
its extirpation), 112 

Glosst skin, 21 

Geiffe in a case of disseminated sele- 
rosis, with lésion of the nerve-cells, 
53 ; in paralysis agitans, 141 

H. 

Hands, deformities of, in paralysis 
agitans, 141 ; in rheumatism, 141-2 

H^MATOMYELiA, 55 ; patliogeny, 55 ; 
diminution or abolition of electri- 
cal contractility, 55 ; altération of 
urine, 108 

Hemian^sthesia,, hysterical, 233, * 
246, 270; historical sketch, 248 ; 
lésions of spécial sensés, 249 ; re- 
lations between hemianœsthesia, 
ovarian hyperajstbesia, paralysis, 
and contracture, 250, 270; char- 
acters wliich separate it from 
bemiauœsthesia of cérébral origin, 
251 

— of encephalic origin, historical 
sketch, 253; its cliaracters,253,255; 
cases reported by Tûrck, 251, 258 

Hemichoeea, 260 

Hemiopia, 233 

Hemipaeaplegia, traumatic, 83 ; 

arthropathies in, 84 ; muscular 

atrophy in, 86; altération of urine 

in, 107 
Hemiplegia in apoplectiform attacks, 

204 ; hysterical, 284 
Herpès zoster (v. Zona) 
HiSTOLOGT, normal, of the nervous 

System, 162 
HypER^MiA, neuro-paralytic, 104, 

110 



HypeEjESThesia, ovarian, 234, 246, 
300 ; its f rcquency, 263 ; historical 
sketch, 263; clinical characters, 
264; anatomical lésions of the 
ovary, 269 ; conclusion, 276 ; clini- 
cal cases, 277, 281, 304 

HTSTERIA («. CONTEACTUEE, EPIDE- 

Mics, Hemianœsthesia, Otaeian 
hyperjEsthesia, Ischtjria, Se- 
coues), epileptiform, 302 ; ovarian, 
247 ; severe, 251, 276 ; local, 263 
Hystero-epilepsy, 271, 300; meaning 
of the term, 301; with distinct 
crises, 303 ; varieties of, 303 ; 
nature of, 305; température in, 
307 ; hystero-epileptic acme, 311 ; 
severe cases of, 312 

I. 

Immobilisation of members (efPeets 
of), 9, 13 

Incoordination, motor, 189 

Infection, purulent, sequela of bed- 
sore, 74 

Intoxication, putrid, sequela of bed- 
sore, 73 

Ieeitability, muscular, 32 

Irritation (rôle of) of nerves in the 
production of trophic dérange- 
ments, 18 

Ischœmia, hysterical, 249 

IsCHURiA, hysterical, 225 ; transient, 
227; permanent, 228 ; historical 
sketch, 229 ; simulation, 230 ; dif- 
fers from ischuria caused by cal- 
culus, 232 ; clinical case, 233 ; dia- 
grams indicating amountof vomited 
matter and of urine, 236 ; chcmical 
analyses, 237-8 ; remissions, 237 ; 
reality of, 239 ; comparative be- 
nignityof, 241 ; gravityof calcular 
ischuria, 240 ; mechauism of, 242 

K. 

IviDNEYS (lésions of) consécutive on 
nerve-sections, 106-7 ; expérimental 
contradictions, 17 



Lingual muscles, contractured, 281 

Lepra, anœ^thetic, 27 

Lésions, irritative, 12, 16 ; ociilar, 
consécutive on irritation of the 
Gasserian ganglion, 13, 16 ; on 
section of the trifacial nerve, 13, 
14 ; owing to spontaueous lésions 
of fif th nerve, 15 



324 



INDEX. 



M. 

Meningitis aseendens, simple puru- 
lent, or ichorous, consécutive on 
bed-sore, 75 ; cbronic cervical, 26 

Miracles of St. Louis, 293; of St. 
Medard, 249, 274 

Meduila SPiJSTAiis, cffects o£ trans- 
verse section, 9, 17 

Muscles, trophic or nutritive affec- 
tions of, 28 ; in infantile paralysis, 
57 (». Amyoteophy, Ateophy, 
Mtopathy, Scleeosis, dissemin- 
ated) 

Myelitis, acute central, 54; diminu- 
tion of electrical contractility in, 
54 ; lésions of supra-renal capsules, 
106 ; altérations of urine, 108 ; 
gastric crises, 210 

— partial, aniyotrophy, 53 

— spontaneous, 87 

— traumatic, 80 
Myodynia, hysterical, 264 
Myopathies consécutive on lésions of 

tlie spinal cord, £0 

N. 

Nepheo-cystitis consécutive on spinal 
lésions, 106, 107 

Nepheotomy, 228 ; gravity of, 240 

Neetes, contusion and ligature of , 48 ; 
excision of, 49 ; patches of sclerosis 
on, 161 ; dilator, 116 (v. Choeda 
TYMPANi) ; facial (paralysis of) 
32 ; glandular (irritation of), 122; 
ischiatic (resuit of section of), 9 ; 
secretor (researclies of Ludwig on), 
119 ; trifacial (resuit of section of ), 
10, 13 ; Samuel's experiments, 13, 
124 ; spontaneous lésions, 15; 
trophic, 19, 123; origin of thèse 
nerves, 124; vaso-motor, 125 ; (rôle 
of), in référence to nutrition, 12, 
19 ; irritation of, 115 

Neueitis, 22, 23 ; trophic disorders 
connected with, 24 

Netjeoglia, 164 

NuTEiTiON (influence of the nervous 
System on), 5, 6, and passim 

Nystagmus iu disseminatcd sclerosis, 
192 

0. 

Obliteeation of ureters by calcul!, 
231 ; duration, 232 ; gravity, 240 

Oligueia, hysterical, 227 

OssEODS System (trophic affections of), 
22 

Ovaey (position of), 267 {v. Compees- 
siON, IIypeetesthesia) 

Ovauialoia, hysterical, 234, 250, 270 



Paealysis agitans, 130 ; historical 
sketch, 133 ; nature, 134 ; gênerai 
characteristics of, 134 ; modes of 
invasion, 136 ; symptoms, station- 
ary period, 137 ; tremor, 138 ; 
attitude of body, 140 ; its value in 
diagnosis, 142 ; P. agitans sine 
tremore, 143 ; painful sensations, 
147 ; terminal stage, 149 ; termi- 
uations, 149, 150; pathological 
anatomy, 150; physiological ana- 
tomy, 151 ; causes, 151, 154; treat- 
ment, 155 {v. Peopulsion, Reteo- 

PULSION, UtTEEANCE) 

Paealysis, hulbar, symptomatic of 
disseminated sclerosis, 215 

— consécutive on nerve-lesions, 40 

— gênerai progressive, characters 
which assimilate it to disseminated 
sclerosis, 183, 193 {v. Apoplecti- 

FOEM ATTACES) 

— gênerai spinal (adult), 59 ; its 
analogies and différences with in- 
fantile paralysis, 59 

— hysterical, 235, 290, and passim 

— infantile, 57 ; anatomical lésions, 
57 

— lahio-glosso-laryngeal, lésions of 
the motor cells, 60, 193 

— pseudo-hypertrophie, 40 

— rheumatic (state of the muscular 
contractility in), 34 

Paeaplegia, traumatic (altération of 

urine in), 106 {v. Hemipaeaplegia) 
Paeesis of the lower extremities in 

disseminated sclerosis, 196 ; remis- 

si(ms, 196 
Petit mal, epileptic, 306 
Phaeynx (paralysis of the), 281 
Phlegmon (pseudo-), 21, 71 
Pbeliminary remarks, 4 
Peopulsion in paralysis agitans, 135, 

143, 146, 319 
PuLSE in apoplectiform attacks, 208 
Putamen, 256 

R. 

Remissions, 137, 196 

Rétention of urine iu hysterical cases, 

227. 288, 289 
Reteopulsion in paralysis agitans, 

135, 146, 319 
Rigidity ce tue limbs and neck in 

paralysis agitans, 140 {v. CoNTEAC- 

tuee) 

S. 
Salivation in paralysis agitans, 140 

SCLEEODEIIMA 21 



INDEX, 



325 



Sci^nosiStfasciculated, 51 

— descending , 204 

— latéral, in hysteria, 294 

— posterior, complicating dissemi- 
nated sclerosis, 198 {v. Ataxia, 
iocomotor) 

— dissemhiated {en plaques), lésions 
of motor-cells in, 52, 53 ; lésions 
of the bulbus in, 60, 160 ; and 
paralysis agitans, 151 ; historical 
sketch, 133; macroscopic anatomy, 
159; distribution of sclerosed 
patches in brain, 160 ; in spinal 
cord, 160 ; on tbe nerves, 161 ; as- 
pect of sclerosed patches, 161 ; bis- 
tology, 169; altération of vessels 
in, 174; nature of the lésion, 176, 
181; spinal form, 161, 216; cepba- 
lic or bulbar form, 161,' 216 ; cere- 
bro-spinal form, 184, 216 ; causes of 
error in diagnosis, 184; diplopia, 
191; amblyopia,191; cephalic symp- 
toms,191; nystagmus, 192; vertigo, 

194 ; faciès, 194; psychic symptoms, 

195 ; state of lower extremities, 

196 ; unusual symptoms, 197 ; 
ataxia, 198; muscular atrophy, 199; 
conti'acture of limbs, 200 ; spinal 
epilepsy, 200, 285 ; apoplectiform 
attacks, 204 ; periods, 209 ; remis- 
sions, 211 ; gastric crises, 212 ; in- 
tercurrent diseases, 214; bulbar 
paralysis, 215 ; duration, 216 ; pa- 
thological physiology, 217 ; causes, 
219; influence of acute diseases, 
219; prognosis, 220 ; treatment, 221 

" Secoues " {les) in relation to the 
convulsionnaires, 273 

Sections of nerves, complète or in- 
complète, 19, 23, 30, 46, 175 

Simulation in hysteria, 230 

Spasm {v. Conteactuee) 

Speech {v. Uttebance) 

T. 

Taeantism, 278 

Tempebatuee (significance of decrease 
of. in cérébral apoplexy), 78 ; dimi- 
nution of, accompanying irri- 
tant nerve-lesiona, 113 ; dépendent 
on irritation of the great sympa- 
thetic (cervical), 115 

— in paralysis agitans, 148 

— in apoplectiform attacks, 208 

— in hystero-epileptiform attacks, 
307 

— in epileptiform acme, 308 

— in hystero-epileptiform acme, 312 



ToNGUE (contracture of), 281 

Theemo-an^sthesia, 248 

Teemoe, in gênerai, 130 ; différence 
as regards repose and movcment, 
130; varieties, 132 ; historical 
sketch, 133 

— \n paralysis agitans, 138, 188 

— in disseminated sclerosis, 186 ; 
influence of movements, 187 ; char- 
acters distinguishing it f rom chorea, 
189 

— motor incoordination, 190 
Teepidation, provoked, of the foot in 

hysteria, 289 

— in sclerosis of the latéral columns, 
289 

— in disseminated sclerosis, 289 

— in descending sclerosis, 289 (note) 
Teismus, 234 

Teophic dérangements, 5 ; différ- 
ences distinguishing them from 
passive lésions, 9 ; consécutive ou 
lésions of tbe peripheral nerves, 6 ; 
traumatic causes, 22 ; spontaneous 
lésions, 24 ; theoretical views, 1C9 ; 
vaso-motor theory, 110; attraction 
theory, 121 ; trophic-nerve theory, 
123; Samuel's theory, 124; criti- 
cisms, 125 ; conclusions, 126 ; in 
disseminated sclerosis, 213 

Tubeecle of spinal cord, 93 

Tympanitis, 234, 288, 290 

U. 

Ueea in hysterical vomited matter ; in 
alvine évacuations after nephro- 
tomy ; influence of pressure on its 
production, 228, 237, 239, 244 

Ueetees (spasmodic contracture of), 
(«. Obliteeation) 

Ueticaeia in Iocomotor ataxy, 64 

Uttebance (modifications of) in para- 
lysis agitans, 139 ; in disseminated 
sclerosis, 192 

V. 

Veetigo, in disseminated sclerosis, 194, 

212 ; epileptic, 306 
VOMITING, hysterical, 238, 241 

— urœmic, 228 

— of blood, 288 

Z. 

Zona, 20, 24, 26 ; in Iocomotor ataxy, 
64 ; dépendent on partial lésions of 
encephalon, 67 ; with modifications 
of the derm, 91 ; local élévation of 
température, 113 

Zostee, herpès {v. Zona) 



eeeatum. 
Page 93, Unes 23 and 28,/or " paraplegit " read " hémiplégie. 



PEINTED BY 
ADLARD, BABTHOLOMEW CLOSE. 



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